Sometimes getting your health insurance company to cover necessary medical expenses is like playing a big game without knowing the rules. The large professional insurance companies know all the rules and the members are just learning how to play the game. But every game has a rule book and for health insurance it can be call the Evidence of Coverage, Member Agreement, or Certificate of Coverage. The federal government is finally forcing the insurers to publish this rule book of coverage and benefits before consumers enroll in a health plan so they can make an inform enrollment decision.
Rule book of health plan coverage and benefits
One of my biggest gripes during the open enrollment for individual and family plans for 2014 and 2015 was that people had to purchase a health plan before some of the health insurance companies and health plans had even released the Evidence of Coverage (EOC). The EOC is important because it spells out all the rules and regulations for the covered benefits in the health plan. These rule books are published not only for individual family plans, but small and large employer groups, Medicaid, Medi-Cal, Medicare Advantage, dental and vision plans.
Evidence of Coverage outline
The EOC is the fine print for most of the health plan. There may be additional coverage documents for pediatric dental and vision and covered prescription medications called a drug formulary. The EOC will cover
- The rights and responsibilities of the members and the insurer
- How to access care, urgent services, cost sharing, second opinions, and submitting a claim form
- How out-of-network health care services are covered, if at all.
- Prior authorization, discharging planning, case management and palliative care
- Principal benefits and coverage such as acupuncture, ambulance, bariatric surgery, clinical trials, family planning, mental health, rehabilitation, skilled nursing, transplant benefits and many more.
- Principal limitations of the plan such exclusions and limitations, duplicative coverage, claims review and third party liability.
- Grievance process in the event that coverage for a health care service is denied.
Appealing a call to instant replay
While most health care services are pretty straight forward (office visits, labs, test, x-rays, Emergency Room visits), accessing some care or getting the health plan to cover the expense can have the health plan member entering complicated game – whose on first? And as much as we may not like the call by the umpire, the ruling is usually correct when we check the rule book – infield fly rule. However, there are some calls that can be argued and appealed to instant replay. This requires filing an appeal with the regulatory agency that has authority over the health plan, either the California Department of Insurance or the Department of Managed Health Care.
EOC can change like the weather
The Insurance companies can subtly change the EOCs every year, usually in their favor. So it is important to at least glance at the EOC before renewing enrollment in a health plan for the next year or to compare your current plan with a similar plan offered by another carrier. This can be helpful if you anticipate changes in your or a family member’s health care utilization.
- Drug formulary
- New and innovative therapies or procedures
- Organ donation
- Out of network rules and coinsurance
- Transgender health services
New rules for consumer transparency
The Centers for Medicare and Medicaid Services announced in June the final rules insurers must follow for releasing the EOCs before open enrollment. Download the final regulations and summary at end of post.
The Departments of Health and Human Services (HHS), Labor, and the Treasury today issued final regulations to make it easier for people and employers to compare their options when shopping for and renewing health insurance coverage. These rules also implement streamlined processes to help health insurance issuers and group health plans provide consumers easy to understand information.
The rules enhance the consumer shopping experience in a number of ways. For example, health insurance issuers must provide online access to a copy of the individual coverage policy for each plan or group certificate of coverage. And these documents must be made publicly available to all potential consumers prior to when a consumer applies, so they are clearly informed about what a plan will and will not offer. The final rules make few changes to the rules proposed in December 2014.
Notification of abortion coverage restrictions
In addition to making the EOCs available for review for comparison shopping, the CMS rules also require that the health plan spell out any coverage or restrictions on abortion services.
Section 1303(b)(3)(A) of the Affordable Care Act, and implementing regulations at 45 C.F.R. 156.280(f), which already apply to qualified health plan issuers offering coverage that covers abortion services for which public funding is prohibited through an individual market Marketplace, require such issuers to notify consumers of such coverage at the time of enrollment. Unchanged from the proposed regulations, the final regulations require such a QHP issuer to disclose on the SBC whether non-excepted abortion services as well as excepted abortion services (that is, those abortion services for which public funding is permitted) are covered or excluded, consistent with the manner specified in guidance by the Secretary.
Know the rules, win the game
When consumers have access to good information they can make informed choices. When consumers have access to the rule book for the game of health care coverage, they have a better chance of making informed health care decisions that reduce their out of pocket costs or fighting the insurance company to get a service covered.