How to define certain terms that are not defined in the ACA glossary but are to be defined on the Summary of Payments (SOP) form.
The Division suggests the plans consider the following sample definitions, although the Division would find it acceptable if plans use alternate definitions so long as they are similar to the ones listed below:
- Health plan discount – Your plan negotiates discounts with providers. This discount is the amount you saved off of the provider’s billed charge because you are a member of your health plan.
- Health plan covered – This is the portion of the amount billed that is paid by your plan less any amounts owed by you due to the copayment, coinsurance, or deductible payments required under your health plan.
- Service (provider) charge – This is the total amount charged by the provider.
- Your share/you owe – This is the portion of the amount billed that you owe the provider. This does not reflect any payment you may have already made at the time of care.
- Not covered – This is the portion of the amount billed that is not covered by your plan.
Should carriers include subscriber information on a form that is not being sent to the subscriber?
In the member information section of Bulletin 2017-02’s Exhibit A, it is stated that carriers should include a “subscriber’s name and address” and “subscriber ID number” – when the form is being sent to the member and not the subscriber.
To alleviate member confusion, when the form is being sent to the member and not the subscriber, the Division would find it acceptable if plans only list the member’s name, address, and ID number.
Would it be acceptable for health plans to display only the allowed amount or only the discount amount, rather than displaying both the allowed amount and the discounted amount?
To alleviate member confusion and to be consistent with the “and/or” provision in the Billing and Disposition Section of Bulletin 2017-12’s Exhibit A, the Division would find it acceptable if plans only included the Health Plan Allowed Amount or the Health Plan Discount, as determined appropriate by the plan.
Who can request an alternative method for receiving an SOP?
The following provisions as identified in the bulletin:
“All carriers shall permit any (i) subscriber who is legally authorized to consent to care for the insured member, (ii) insured member who is legally authorized to consent to her or his own care, or (iii) other party who has the exclusive legal authorization to care for the insured member, to choose in writing an alternative method of receiving the SOP.” and;
“All carriers shall also permit another party legally authorized to consent to care for an insured member to request […] to receive the forms on behalf of the member […] provided that the third party clearly states in writing that disclosure of all or part of the information could endanger the requesting party or the insured member.”
The first provision limits who can request an alternative method for receiving an SOP in any circumstance, while the second provision details who can request an alternative method for receiving an SOP when the member or third party raises concerns in writing about endangerment.
What is expected in the Consumer Assistance section as identified in Bulletin 2017-02’s Exhibit A? How should that differ from providing “customer service contacts” or “how to contact the carrier with questions”?
To prevent member confusion, the SOP should be directing members to call the plan’s member services department for any assistance.
Would plans be permitted to use a hybrid approach to providing SOPs for all claims?
The Bulletin notes that “[i]n lieu of sending a SOP for every claim the Carrier pays, the Carrier may issue a document summarizing all claims paid during a reporting period no less frequently than quarterly.”
In lieu of sending the common SOP for services without cost share, the Division would find it acceptable if plans utilize a hybrid approach to providing SOPs to members, including:
- Example 1: A common SOP is triggered for only those claims with member liability, in either paper or electronic format, AND the members are provided access to detail of claims as close to real time as possible but no greater than every 45 days.
- Example 2: A common SOP is triggered for only those claims with member liability, in either paper or electronic format, AND the member has electronic access to a quarterly roll-up of all claims
Would it be acceptable for the plan to accept an electronic request including one received from the member on its member portal?
The Bulletin notes that the “preferred method of receipt shall be valid until the insured member submits a request in writing for a different method.”
A request on the member portal, if accepted by the plan, with appropriate safeguards, such as an electronic signature or confirmation of identity would satisfy the “in writing” requirement.
Is it the intent of the DOI to require carriers to document complaints that come into Member Services for reporting purposes to the DOI?
The Bulletin notes that the “Division shall issue requirements for reasonable reporting by Carriers to the Division regarding compliance and the number and type of complaints received regarding noncompliance with this Bulletin.”
The data will be aggregate counts and will not require disclosure of PHI or PII information. In addition, categories of types of complaints will be defined in separate guidance from the Division.
Is it required that the SOP template look the same as what is attached to the bulletin OR may the Carrier deviate from the SOP template as long as their form has all the required fields per the bulletin?
Carriers may deviate from the format of the SOP template as long as the SOP has all the required fields.
May a Carrier add more fields or language in addition to the pre-defined fields and language specified in the Bulletin?
Yes, as an example carriers could include the Patient’s address, a confidentiality statement, etc.
Compliance Date?
August 1, 2017 – Plans should submit your draft revised SOP via SERFF to the Division. There will be opportunities for redrafting between August 1 and February 1, 2018.
February 1, 2018 – To the extent they have not otherwise developed transition plans with the DOI, plans should come into compliance with the Standards for Common Summary of Payments Forms and the Delivery of SOP Forms section of the bulletin.
The Division expects Carriers to submit a revised draft SOP and transition plan(s) for subcontractors or vendors (if applicable) by November 1, 2017. If any Carrier believes that it is unable to come into final compliance by February 1, 2018 with the Standards for Common Summary of Payments as identified in Bulletin 2017-02, then the Carrier should be in contact with the Division to discuss its process to come into compliance at the earliest possible date.