National Association of Insurance Commissioners Health Insurance Committee To Review Patient Protection and Affordable Care Act standards for a Summary of Benefits and Coverage Explanation for Individual and Group Health Insurance

Jun 20, 2011


As part of its scheduled meeting on Wednesday, June 22, 2011 at 2:00 p.m. (ET), the National Association of Insurance Commissioners’ (“NAIC”) Health Insurance Committee will discuss and consider for adoption a draft of “coverage facts labels” developed by the Consumer Information Subgroup pursuant to the Patient Protection and Affordable Care Act (“PPACA”).

The PPACA requires the U.S. Secretary of Health and Human Services to develop standards for a summary of benefits and coverage explanation for individual and group health insurance.  In developing these standards, the law directs the Secretary to consult with the NAIC, along with a working group composed of representatives of health insurance-related consumer advocacy organization, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.

To accomplish this, the Subgroup formed a “Coverage Facts Small Group” to focus exclusively on the development of the labels. Georgetown University provided members of the Small Group with published treatment plans, Current Procedural Terminology  codes and associated dollar values for three common medical scenarios:  maternity, breast cancer and diabetes. 

Blue Cross Blue Shield of Florida created a manual Excel spreadsheet and applied two of their plans to the Georgetown data to generate simulated patient expenses due to cost sharing, coverage limits and exclusions.  Two potential formats for displaying the label were developed based on this initial simulation.  However, it is important to note that these exercises did not examine automated means for producing the forms, which many insurance carriers will need to implement in order to provide consumers with coverage facts labels for their products in the most cost-efficient way.


To preview the Standard Definitions and Standards for the Summary of Benefits and Coverage developed by the NAIC’s Consumer Information Subgroup, click on the hyperlinks below:


All materials for the June 22 meeting will be posted to the following Web page: