Mandated consumer-friendly health insurance is coming—dreaded requirement or welcomed opportunity?


It’s a common tale.

Your members call into the contact center because they [pick one]:

  • Received an explanation of benefits, which denied a claim for a service they believed they were covered for – “How is emergency care on the weekend different than visiting my doctor during the week?"
  • Received an invoice from their primary care physician for what they thought were routine services – “We signed up for ‘wellness’ so why did the doctor send me a bill for my son’s back-to-school yearly checkup?”
  • Received an ID card that only states the account owner’s name, but not the names of his/her dependents – “If we signed up for family coverage why does only my name appear on the card?”
  • Went online to check the status of a claim they submitted because after three weeks they were not yet reimbursed – “What does it mean when my claim’s status is ‘pending adjudication due to non-verifiable co-insurance maximum values for the current plan year?’”

These are not exactly the exceptional customer experiences promised to the member by their agent or by their employer’s HR manager.

The triggers for these communications were all legitimate based on the members’ chosen plans. But the aftermath generated negative consumer experiences. Not only did the members not fully understand what they originally bought into, but (even worse) they didn’t understand their ongoing relationship with you, either.

Consistent messaging, across all channels and at appropriate intervals, is essential to improving the customer experience. Members should hear one voice. Everywhere. Every time.

To all those health insurance marketers who always felt that progress towards improving customer experience was being hijacked by the antiquated systems (or attitudes) of operations and IT folks, we have good news. The Centers for Medicare and Medicaid Services (CMS) will soon be issuing a proposed rule requiring health insurers to develop standardized, consumer-friendly summaries of benefits and coverage under their health plan packages.

The rule would cover all benefit packages including those that individuals and small employers will be able to compare and purchase on Web-based state insurance exchanges. It is currently being reviewed by the Office of Management and Budget, which is one of the last steps before publication in the Federal Register.

How will this affect you? The new regulation will mandate that all health insurers standardize, in consumer-friendly language, definitions for medical terms that will cover hospitalization, emergency room care, skilled nursing care and hospice services, among others. It will also include insurance terms that cover premium, co-insurance, out-of-network co-payments, grievance and appeals.

Leading companies such as Apple, American Express, Southwest Airlines, Liberty Mutual and Humana have been establishing customer experience best practices by anchoring their brands to simplicity. Perhaps this new mandate will serve as an opportunity for health insurers to not just standardize language, but also to simplify the overall member experience.


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