Sec. 202. Requirements for notice regarding benefits
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Each applicable health plan shall offer to consumers, prior to enrollment, enrollment material that includes— a plain language explanation of the benefits included in such plan, including through forms that are culturally and linguistically appropriate for such consumers; and a warning page regarding such benefits in accordance with subsection (b). The warning page required under subsection (a)(2) shall include— a clear statement indicating that the applicable health plan is not a comprehensive health plan because it is not required to comply with certain requirements under the Patient Protection and Affordable Care Act ( Public Law 111–148 ) and title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg et seq.); a statement encouraging the consumer to review the plan documents carefully to ensure the individual is aware of— any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services); and any lifetime or annual dollar limits on health benefits; a statement notifying the consumer that, if the plan expires or the individual loses eligibility for the plan, the individual may have to wait until the beginning of an open enrollment period to enroll in another plan; a statement notifying the consumer of the option to enroll in a qualified health plan, which is generally a more comprehensive health plan, through the Exchange operating in the State, including— a statement that most consumers who enroll in a qualified health plan receive help paying for their monthly premiums; a statement that special enrollment periods are available through the Exchange; a link to Healthcare.gov (or a successor website) or another website for the Exchange operating in the State; and the phone number for the Exchange operating in the State; and a line for the signature of the consumer to acknowledge that the consumer has read and understands the provisions in the warning page, and for the date on which such signature is provided.
The warning page required under subsection (a)(2) shall be— located at the beginning of the enrollment material, accessible to people with disabilities, including a physical, cognitive, or sensory disability, including accessibility to such people through the use of computers and other technology for receiving consumer information; and written in plain language that is easily understood by individuals with an intellectual or other cognitive or processing disability. An applicable health plan shall make the warning page required under subsection (a)(2) available in the top 15 languages spoken by individuals with limited English proficiency in the State in which the plan is offered.
The warning page required under subsection (a)(2) shall not include any provision— promoting enrollment in any non-ACA compliant health insurance coverage; or directing consumers to a source that could enroll the consumer in any non-ACA compliant health insurance coverage. A State may require applicable health plans to include information, in addition to the information required under this section, in the warning page required under subsection (a)(2), except that any such additional information shall not— replace the information required under this section; promote enrollment in any non-ACA compliant health insurance coverage; direct consumers to a source that could enroll the consumer in any non-ACA compliant health insurance coverage; or otherwise conflict with a requirement under this section.
An administrator of an applicable health plan shall maintain a record of the signature of a consumer obtained under subsection (b)(1)(E) while the consumer is enrolled in the plan and for, at a minimum, 2 years after the consumer is no longer enrolled in such plan. The Secretary may, through regulations under section 205, require an applicable health plan to maintain such record for a period longer than 2 years after the consumer is no longer enrolled in the plan. In the case that a consumer claims, within the period and in accordance with the procedures described in subparagraph (C), that an applicable health plan did not cover a health benefit while the consumer was enrolled in such plan and the administrator of such plan is not able to provide proof of the record required under paragraph
(1)with respect to that consumer, the plan shall reimburse the consumer, in an amount determined under subparagraph (B), for such benefit. Except as provided under clause (ii), such reimbursement shall be equal to (the greater of)— the amount the applicable second lowest cost silver plan (as defined in section 36B(b)(3)(B) of the Internal Revenue Code of 1986), available in the Exchange operating in the State in which the consumer resided at the time of enrollment, would have paid for the health benefit if the consumer were enrolled in such plan and the health benefit was provided in-network; or if applicable, an amount determined by the State in which the consumer resides at the time of enrollment. In the case described in subparagraph (A), if the Secretary or applicable State authority determines that the applicable health plan was required to provide coverage of the health benefit claimed by the consumer based on statements included in the plan documents, the applicable health plan shall reimburse the consumer in an amount determined in accordance with such plan documents. The Secretary shall, through regulations under section 205, establish procedures for the filing of claims under subparagraph (A), including by setting the period during which a claim under such subparagraph shall be filed. Such period shall be not less than 2 years after the consumer is no longer enrolled in the plan. The ability of an applicable health plan to produce proof of a record required under paragraph
(1)shall not shield the plan, including any administrator, insurance broker, or operator of the plan, from liability under other applicable State or Federal law for any deceptive practice that the plan, including any such administrator, insurance broker, or operator, engaged in while enrolling a consumer in the plan.
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- Pub. L. 111-148
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