Know Your Documents


To get the most out of your health plan, it's important that you understand what the plan covers and how it works. State and federal laws require plans to cover certain benefits and to give you certain protections, but each plan works a little differently. The following documents help you understand how your plan works. With the exception of your actual policy, insurers must make all of these documents available to you when you're shopping for coverage. Use them to compare benefits and choose the best plan for your needs.

Your Policy

Health plans are legal contracts between you and the health insurance company or health maintenance organization (HMO). A plan issued by a health insurance company is called a policy, while a plan issued by an HMO is called an evidence of coverage (EOC). The policy or EOC outlines your rights and responsibilities under the plan.

You will get a copy of your policy or EOC after you have enrolled in the plan. This document will be much more detailed than the other documents, which only summarize your coverage. Review your policy or EOC carefully, especially if you have significant health needs. If you aren't satisfied with the policy, you have 10 days after receiving the policy to return it and get a refund of your premium.

Your Outline of Coverage

The company must give you an outline of coverage when you apply for a plan, and a copy is often provided along with your policy or EOC. This document provides a high-level summary of the plan's benefits, exclusions, and cost-sharing requirements. Review your outline of coverage to get a basic understanding of how your plan works. Make sure you read the policy or EOC for a more detailed understanding.

Your Summary of Benefits and Coverage

The summary of benefits and coverage provides information that is similar to the outline of coverage, but the format is standardized across plans. This makes it easier to compare one plan to another. The summary outlines the basic coverage and costs of your plan, including:

The following sections will explain these terms in detail.

In addition, your summary of benefits and coverage gives examples of what you and your plan might pay for some medical costs, such as having a baby or managing diabetes. It also has a glossary of common medical insurance terms.

Your Plan Disclosures

Health plan disclosures describe the detailed terms and conditions of your policy. Although companies aren't required to give you the policy document or EOC before you buy a plan, they are required to give you plan disclosures if you ask for them. PPO plans are also required to post plan disclosures on their websites.

Plan disclosures must include an explanation of:

  • all covered services and benefits, including prescription drug coverage
  • emergency care benefits and information on access to after-hours care
  • any limitations or exclusions
  • your financial responsibility for payment of premiums, deductibles, copayments, coinsurance, and other out-of-pocket expenses
  • the distinction between preferred providers and nonpreferred providers and the difference in how the plan covers services from preferred versus nonpreferred providers
  • any preauthorization requirements and any penalty associated with failure to get required authorizations
  • complaint resolution procedures
  • the plan's service area
  • out-of-area services and benefits
  • how to find a current preferred provider directory
  • information about the adequacy of your network.

Your Preferred Provider Directory

A health plan's preferred provider directory lets you see which physicians, hospitals, and other health care providers are considered to be in-network. You should review a plan's provider directory to make sure the plan will cover the providers you want to see before you make an appointment. If you don't have a doctor, the provider listing will help you find one. The provider listing will also provide transparency on which in-network hospitals put you at risk of balance billing from out-of-network hospital-based physicians. The following sections will explain networks and balance billing in more detail.

Plans must make provider directories available online that are updated as providers enter and leave the network throughout the year. You also have the right to request a paper copy of the provider directory.

Your Prescription Drug Formulary

A health plan's drug formulary lists the prescription drugs covered by the plan and indicates the cost-sharing tier associated with different drugs. Most plans charge different amounts for generic drugs, brand name drugs, and specialty drugs. Make sure you understand your plan's formulary so that you don't face surprises at the pharmacy. If you're concerned about the cost of a prescription, ask your doctor if a generic or other lower cost drug is available.

The formulary should be available with plan disclosures before you purchase a plan, or with the policy or EOC after you purchase a plan. However, it is usually included as a separate document. Some plans may also make formulary information available through a website search tool.

Next Section: Know Your Coverage

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Last updated: 05/22/2018