State: Health plans must make documents readable

Health plans rarely say things in easily understandable language, says John A. Cogan, executive counsel for the R.I. Office of the Health Insurance Commissioner. Instead, they use complicated, even inscrutable language that can befuddle even a lawyer like himself.
So how is a typical consumer supposed to make sense of it?
Starting Aug. 31 of next year, all health plans in Rhode Island will have to do better. A new regulation that Cogan said will be “the most stringent” in the nation will require all health-plan documents – from certificates of coverage to subscriber agreements to benefits booklets and summary descriptions – to be written at an eighth-grade level or lower.
“That’s the average reading level not only of the people of Rhode Island, but of people across the country,” Cogan said. The new standard “won’t cure bad writing,” he added, “but what it does is it forces insurers to write their policies in shorter sentences and use smaller words.”
To gauge compliance, the state will use the Flesch-Kincaid Grade Level, a formula based on word and sentence length that is actually built into Microsoft Word but can also be found online. (This article scores at the 11th grade level.)
Other states with “readability” standards have used another, related formula, the Flesch Reading Ease, which uses a 1-100 scale, Cogan said, but the minimum standard, usually in the 40s, or around high school level, “is still pretty difficult to read – it’s beyond most people.”
Medicaid regulations, on the other hand, require materials to be written at the fourth- to sixth-grade level, Cogan said, so RIte Care beneficiaries, for example, already get their health plan information in plain English.
Documents from commercial plans, however, can be tough even for college graduates. The regulation includes examples that scored at the 15th, 18th and 20th grade level, and in a recent Op-Ed in The New York Times, Cogan cited a case in which an insurance company had denied cancer care to a Rhode Island patient on the basis of language that the insurer’s own employees admitted they were still trying to sort through. (The patient eventually got care.)
Nationwide, studies have found more than 30 percent of English-speaking Americans have difficulty understanding their health plans, the regulation notes, and that is linked to poor overall health, less use of preventative care, and higher health care costs. And with the advent of high-deductible, “consumer-driven” plans in recent years, Cogan said, readability standards are particularly important.
“High-deductible plans put more responsibility on people for their own health care,” he said. “We wanted to make sure that as more responsibility – both financial and administrative – was shifted to individuals, that they were able to understand their health insurance policies.”
But for insurers, Cogan acknowledged, it’s going to be a lot of work. Of the health plans active in the state, only Blue Cross & Blue Shield of Rhode Island commented on the regulation before it was approved, he said, and some smaller players may not even know about it yet, so his office is actively reaching out to them to ensure they have time to prepare.
“We want to work with the companies,” he said. “We don’t want to drive away any business.” There are exceptions to accommodate language required by law or by labor contracts, and insurers can petition for specific texts to be at a higher grade level. And if an insurer needs extra time, it may be granted. “But the bottom line is, we want our policies readable for most people in Rhode Island,” Cogan said. “That is our goal.”
Christopher Medici, spokesman for Blue Cross, said the company supports the changes but does have some concerns about completing the work in time. There are many “stakeholders” involved, too, he noted, from consumers and employers to brokers to providers to the insurer’s own medical, legal and regulatory staff, and the language must be right for all.
“The goal is to make sure that this information is provided in a clear and effective way but also provided in a way that doesn’t dilute the true meaning or impact of the content,” he said.
Blue Cross already works hard to make consumer-oriented materials easy to read, Medici added – its “Choices” magazine, for example, is vetted by experts but written by people specially trained to make all the articles accessible even for less-educated readers.
Now Blue Cross is doing an inventory of the materials covered by the regulation to determine the scope of the work and how best to do it, Medici said.
Whatever happens, Cogan said he expects the regulation to be adjusted over time as it’s tested against real-life materials and situations. &#8226