Summary Plan Description

Upon enrollment in a health plan, the plan member is provided with a booklet that describes the benefits and limits of the plan. This booklet may be referred to by numerous different terms including a Certificate of Coverage, Benefit Booklet, Summary Plan Description, Health Plan Document or even a Policy.

This booklet is simply a guide to everything you ever wanted to know about a health plan including: what is covered, what is not covered and everything in between.

How is the Summary Plan Description Used?

Insurance carriers refer to this guide as a means to:

  • Document the agreed upon terms and provisions of the plan.
  • Understand and communicate the provisions of the plan.
  • Adjudicate all claims in accordance with the provisions of the plan. 

Patients will refer to this guide as a means to:

  • Understand how they should access care.
  • Determine how to enroll dependents.
  • Understand their rights when employment is terminated.

Providers will refer to this guide as a means to:

  • Understand the benefits and limits of the plan so that the patient can be advised, upfront, of any financial liability.
  • Understand the rules of the plan. 
  • Make sure that the insurance carrier is administering the plan as written and that any gray areas can be clarified without penalty to the patient or the provider. 

Billing Specialists will refer to this guide as a means to:

  • Understand how to appeal all denied or incorrect payments.
  • Challenge a provision or benefit that may not be administered as written or may be unclear.     

From Experience...

Having spent over 30 years in this industry, I continue to use the SPD to help me when I need to draft an appeal letter that hits all of the high points.  

  • The basis for my appeal.
  • The language in the SPD that supports my appeal.
  • Any gray areas that can be interpreted either for or against the service I am trying to get approved. Any ambiguity could work to a member’s favor.  
  • How the item, I am trying to get approval for, compares to other similar, but covered, items in the plan.   

Referring to the SPD helps me to understand whether I even have a basis for appeal.

For example: 

A patient is having hearing problems and after having some hearing tests performed, they determine that a hearing aid is medically warranted for the patient. The SPD is consulted and they exclude all hearing services including hearing aids. 

At this point, an appeal would not change the outcome since the plan clearly excludes coverage for hearing aids.   

What information does the SPD contain?

A Summary Plan Description (SPD) provides pages and pages of detailed information about the plan. Including:

  • Benefits of the plan – deductible, out of pocket, etc.
  • Provisions of the plan
  • What is covered
  • What is not covered
  • How a particular service may be covered i.e., hospital, outpatient, office visit,
  • Plan limits
  • Plan exclusions
  • Requirements of the plans
  • Who is covered
  • How coverage begins and ends
  • Cobra
  • Grievance procedures
  • ERISA
  • Health carrier information
  • Enrollment information
  • Prescription coverage
  • Coordination of Benefits
  • Subrogation
  • General provisions
  • Definitions

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