The Fine Print: Where to Look for Health Insurance Coverage Details

It’s helpful to know not only what your health plan covers—but also what it 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). 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. 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 rarely 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. 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 plan's Medical Guidelines may help.

  • View the Medical Guidelines for some major insurance companies that cover UC members
  • Anthem Blue Cross (Note: effective 1/1/2023 utilization management for CORE, UC Health Savings Plan, and UC Care is controlled by Accolade. Medical guidelines are available from Accolade by request.)
    Health Net (for the UC Blue & Gold HMO)
    Medicare (for the UC High Option and UC Medicare PPO plans)
    Optum (United Behavioral Health) (behavioral health benefits for non-Medicare Kaiser members)
    UnitedHealthcare (for UC Medicare Choice members)

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 Managed Health Care or a federal Independent Review Entity.