Oklahoma’s Workers Comp Opt Out Program vs Obamacare
Oklahoma’s new opt out program legislation is working its way through the very long path to becoming law sometime in 2013. The likely passage of the bill has created quite a buzz on the Workers Comp airwaves.
One of the more interesting areas of the new Oklahoma opt out program is that the Workers Comp benefits must be provided under an SPD (Summary Plan Description). The SPD is the description of all benefits provided to each employee such as health benefits.
The SPD’s are usually provided at the start of employment in most cases. As the SPD’s provide information on health benefits and other federally legislated benefits, the Obamacare law may cause more problems and confusion with Workers Comp benefits under the opt out plans.
The Oklahoma Opt Out Bill will likely be signed by the Governor in the coming weeks. The SPD’s contents are often dictated by Federal Laws. One of the Risk Managers for an employer that is heavily pushing for the opt out program had mentioned this point previously.
The Obamacare bill under Section 2715 – specifically addresses SPD’s calling them summaries. The most important question to ask – If an Oklahoma employer begins an opt out program for Workers Comp, then would the benefits then be considered a health and disability policy? The answer is hopefully not, but likely so.
Section 2715 of the bill has been included below.
‘‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED
DEFINITIONS.
‘‘(a) IN GENERAL.—Not later than 12 months after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage, in compiling and providing to enrollees a summary of benefits and coverage explanation that accurately
describes the benefits and coverage under the applicable plan or coverage.
In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners (referred to in this section as the ‘NAIC’), a working group composed of representatives of health insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.
‘‘(b) REQUIREMENTS.—The standards for the summary of benefits and coverage developed under subsection (a) shall provide for the following:
‘‘(1) APPEARANCE.—The standards shall ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed 4 pages in length and does not include print smaller than 12-point font.
‘‘(2) LANGUAGE.—The standards shall ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee.
‘‘(3) CONTENTS.—The standards shall ensure that the summary of benefits and coverage includes—
‘‘(A) uniform definitions of standard insurance terms and medical terms (consistent with subsection (g)) so that consumers may compare health insurance coverage and understand the terms of coverage (or exception to such coverage);
‘‘(B) a description of the coverage, including cost sharing for—
‘‘(i) each of the categories of the essential health benefits described in subparagraphs (A) through (J)
of section 1302(b)(1) of the Patient Protection and Affordable Care Act; and
‘‘(ii) other benefits, as identified by the Secretary;
‘‘(C) the exceptions, reductions, and limitations on coverage;
‘‘(D) the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations;
‘‘(E) the renewability and continuation of coverage provisions;
‘‘(F) a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing, such scenarios to be based on recognized clinical practice guidelines;
‘‘(G) a statement of whether the plan or coverage—
‘‘(i) provides minimum essential coverage (as defined under section 5000A(f) of the Internal Revenue
Code 1986); and
‘‘(ii) ensures that the plan or coverage share of the total allowed costs of benefits provided under the
plan or coverage is not less than 60 percent of such costs;
‘‘(H) a statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and
‘‘(I) a contact number for the consumer to call with additional questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained.
‘‘(c) PERIODIC REVIEW AND UPDATING.—The Secretary shall periodically review and update, as appropriate, the standards developed under this section.
‘‘(d) REQUIREMENT TO PROVIDE.—
‘‘(1) IN GENERAL.—Not later than 24 months after the date of enactment of the Patient Protection and Affordable Care
Act, each entity described in paragraph (3) shall provide, prior to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by the Secretary under subsection (a) to—
‘‘(A) an applicant at the time of application;
‘‘(B) an enrollee prior to the time of enrollment or
reenrollment, as applicable; and
‘‘(C) a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate.
‘‘(2) COMPLIANCE.—An entity described in paragraph
(3) is deemed to be in compliance with this section if the summary of benefits and coverage described in subsection (a) is provided in paper or electronic form.
‘‘(3) ENTITIES IN GENERAL.—An entity described in this
paragraph is—
‘‘(A) a health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; or
‘‘(B) in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan
(as such terms are defined in section 3(16) of the Employee
Retirement Income Security Act of 1974).
‘‘(4) NOTICE OF MODIFICATIONS.—If a group health plan or health insurance issuer makes any material modification in any of the terms of the plan or coverage involved (as defined for purposes of section 102 of the Employee Retirement Income Security Act of 1974) that is not reflected in the most recently provided summary of benefits and coverage, the plan or issuer shall provide notice of such modification to enrollees not later than 60 days prior to the date on which such modification will become effective.
‘‘(e) PREEMPTION.—The standards developed under subsection
(a) shall preempt any related State standards that require a summary of benefits and coverage that provides less information to consumers than that required to be provided under this section,
as determined by the Secretary.
‘‘(f) FAILURE TO PROVIDE.—An entity described in subsection
(d)(3) that willfully fails to provide the information required under this section shall be subject to a fine of not more than $1,000 for each such failure. Such failure with respect to each enrollee
shall constitute a separate offense for purposes of this subsection.
‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.—
‘‘(1) IN GENERAL.—The Secretary shall, by regulation, provide for the development of standards for the definitions of terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical terms described in paragraph (3).
‘‘(2) INSURANCE-RELATED TERMS.—The insurance-related terms described in this paragraph are premium, deductible, co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCR (usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Secretary determines are important to define so that consumers may compare health insurance coverage and understand the terms of their
coverage.
‘‘(3) MEDICAL TERMS.—The medical terms described in this paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary determines are important to define so that consumers may compare the medical benefits offered by health insurance and
understand the extent of those medical benefits (or exceptions
to those benefits).
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