The fine print: Where to look for health insurance coverage details
It can be very helpful to know what your health plan covers. It can be even more important to understand what your plan doesn't cover.
Evidence of Coverage documents - Is it covered?
Look for coverage guidance in the detailed document for your plan known as the plan booklet or Evidence of Coverage (EOC) or Plan Booklets. EOCs are summaries of the contracts between insurance companies and the University of California. You will find a great deal of helpful information in your EOC, including information about coverage limitations and exclusions. For example, a common exclusion in health plan contracts is for care that isn't medically necessary.
Examples: Want to know what copayment to expect for your ER visit? Wondering if hearing aids are covered? Want to understand your coverage for infertility treatments? Check your health plan's EOC.
Medical Guidelines - Is it Medically Necessary?
UC's contracts with insurance companies do not usually go into detail about coverage for the many and various types of medical procedures offered by health care professionals; there are simply too many to name, and new technologies and techniques are constantly being discovered and refined. However, to find out more about whether a particular procedure or service may be covered, it can be useful to scrutinize the Medical Guidelines that insurance companies use to make coverage decisions. Clinical Practice Guidelines illustrate the standards of care that insurance companies expect health care professionals to provide. Medical Policy and Utilization Management Guidelines offer a view of the rationale used by insurance companies to determine whether equipment, procedures or services are considered to be medically necessary, sometimes by citing relevant scientific literature. These guidelines can be difficult to understand as their target audience is health care professionals, but they can also be useful to patients who want to research their options.
Examples: Need to know when your plan considers speech therapy to be medically necessary? What criteria must be met before a motorized wheelchair would be considered medically necessary? What about similar minimum requirements for inpatient rehabilitation for an alcohol abuse problem? Your insurer's Medical Guidelines may help.
What if your insurer says no?
If your health plan denies your request for medical services or a treatment because the insurance company considers the care to be experimental or not medically necessary, you can appeal their decision. For more information about your appeal and grievance rights, consult your Evidence of Coverage. Depending upon your plan and whether you have Medicare, your EOC will also provide information about assistance from governmental agencies such as the California Department of Insurance, the California Department of Managed Health Care, or a federal Independent Review Entity.