The ACA requires the Secretary of HHS to develop standards for
insurers to use in preparing a summary of benefits and coverage.35 The
current standards (or template) focus on costs to the policyholder, including
premiums, deductibles, co-insurance, co-payments, and out-of-pocket
limits.36 The template lists terms for services in generic language, like
emergency room services, urgent care, prenatal and postnatal care,
http://hepc.liverfoundation.org/treatment/the-basics-about-hepatitis-c-treatment/what-medications-are-used-to-treat-hepatitis-c/ (last updated Apr. 2015). Another example is
variation in substance abuse treatment. The Massachusetts Association of Health Plans
(MAHP) noted that commercial health plans cover most of six FDA-approved medications
to treat opioid addiction, but not Methadone. See Letter from the Mass. Ass’n of Health
Plans to the Mass. Div. of Ins. (Sept. 26, 2014) (on file with author) (discussing treatment for
opioid addiction). See also MASS. ASS’N. OF HEALTH PLANS, OPIOID ADDICTION TREATMENT:
EVIDENCE BASED MEDICINE, POLICY, AND PRACTICE, II ON POINT: HEALTH POLICY BRIEF 2-5
(2015), available at http://www.mahp.com/unify-files/MAHPOnPoint_March2015_
Opioid.pdf (arguing that opioid addiction treatment should include a full range of therapies,
including medication, in addition to more costly inpatient therapy, which is most often
35. 42 U.S. C. A. § 300gg-15 (West, Westlaw through P.L. 113-296, excluding P.L. 113-
235, 113-287, and 113-291) (“[T]he 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 applicants, enrollees, and policyholders or
certificate holders a summary of benefits and coverage explanation that accurately describes
the benefits and coverage under the applicable plan or coverage” and the explanation is to
include a description of the coverage for each of the EHB categories, as well as exceptions,
reductions, and limits on coverage).
36. Summary of Benefits and Coverage Template, Ctrs. for Medicare & Medicaid Servs.
1-2, available at http://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/sbc-template-accessible.pdf.
37. Id. at 2-3.
38. Glossary of Health Coverage and Medical Terms, Ctrs. for Medicare & Medicaid
Servs. 1-2, available at http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/
39. Id. at 3.
40. See Daniel Schwarcz, Transparently Opaque: Understanding the Lack of
Transparency in Insurance Consumer Protection, 61 UCLA L. Rev. 394, 423-24 (2014)
(suggesting that the ACA requirements could be a model for property/casualty and other
lines of insurance to enable consumers to compare policy terms in a standardized format).