New Requirements for Health Plan SPDs

[Guest 1 Mary]

Under the new SPD requirements for health SPDs there are content and disclosure requrements that must be in place 01-01-03 - would these requirements apply to all employer sponsored medical plans - we have 2 self-funed medical plans and 26 fully insured HMO plans.

[Guest b2kates]

Yes. remember back to those bleak days of Section 89.

You need a wrap document. Usually plain english explanation for HMO plan wrapped by company explanation of eligibility and benefit claims procedures.

[Guest joebellis]

Additionally, don't overlook the requirement for a complete listing of providers that must be part of the SPD or accompany it.

[mroberts]

For the listing of providers, I believe you can make note of the insurance carrier's website since that has the most up to date listing. The government realize this listing changes daily and that giving everyone a complete hard copy would be a waste of paper and time.

[Guest joebellis]

Afraid not, the new SPD requirements require that a provider listing accompany the SPD.

The DOL supplied the following in response to our inquiry on this matter:

Regarding the definition of "provider listing", the intent of the Department is delineated in the final ruling:

The preamble of the final rule amending the regulations governing the content of the Summary Plan Description (SPD) states that the purpose of amendment is to implement information disclosure recommendations of the President?s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, as set forth in their November 20, 1997, report, "Consumer Bill of Rights and Responsibilities." Specifically, the amendments clarify benefit, medical provider, and other information required to be disclosed in, or as part of, the SPD of a group health plan and repeal the limited exemption with respect to SPDs of welfare plans providing benefits through qualified health maintenance organizations (HMOs).

The preamble as states "participants and beneficiaries will be in the best position to evaluate and assess their medical provider options when they can review a complete listing of the providers available to them under the terms of the plan, rather than having to inquire on a service-by-service or provider-by provider basis. For this reason, the Department is retaining the requirement that detailed provider lists be furnished automatically, without charge, to participants."

The Consumer Bill of Rights and Responsibilities defines detailed provider lists as: A detailed provider listing should consist of the names, board certification status (if applicable), and geographic location of all contracting primary care providers, specialists, specialty care centers, hospitals, home health agencies, rehabilitation and long-term care facilities; whether they are accepting new patients; language(s) spoken and availability of interpreter services; and whether they are accessible to people with disabilities.

The amendment to the regulation governing content of SPDs requires delivery with the SPD a complete, detailed listing of the providers that participant or beneficiary is eligible to utilize.

Ms. Nalini Close

Pension Law Specialist

Division of Coverage, Reporting and Disclosure

Office of Regulations and Interpretations

Pension and Welfare Benefits Administration

U. S. Department of Labor

Additionally, as my company is just beginning our plan year (3-1), we contacted our ERISA counsel and received acknowledgement that a detailed provider listing was required to accompany the SPD for each of the plans that our company offers. We are in the process of securing complete directories from our carriers.

[mroberts]

That's interesting because I sat through a legal class on this approximately a year ago and they didn't outline it this way. It's possible that everyone wasn't 100% clear as to what is going to be needed since we were discussing the propsed regs which were approved just after the class. Is there a possibility that there's more than one way to skin the cat although the info you just gave is pretty clear?

What is the company supposed to do when providers are added and providers are lost?

[Guest joebellis]

Regarding the update of provider information, many plan provider directory contain the disclaimer that indicates the provider listing is subject to change.

The plan that we ulitize uses the following "The information on United Healthcare contracted doctors and hospitals is updated frequently. While we take care to make our directory complete and accurate, oversights can occur. Doctor and hospital contracts also might become effective or end after the directory has been posted.

United Healthcare does not guarantee any doctor or facility's participation throughout your benefit period. To be sure, call the United Healthcare customer service telephone number listed on your member ID card to find out if the doctor or hospital is in our network."

We simply incorporated that language into our SPD.