Fact Sheet #2

Getting and Using Health Plan Evidence of Coverage

This fact sheet is intended to help Navigators answer specific questions that people with disabilities might ask about getting and using health plans’ Evidence of Coverage documents when purchasers are considering buying health insurance through the Marketplace

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Q1. What is Evidence of Coverage?

A. The Evidence of Coverage (EOC) is a document that describes in detail the health care benefits covered by the health plan. It provides documentation of what that plan covers and how it works, including how much you pay. The EOC can also refer to a certificate or contract provided to a health plan member that contains information about coverage and other rights.

See the fact sheet on “Summary of Benefits and Coverage (SBC)

Q2. Can I get the Evidence of Coverage for a plan I am considering buying?

A. First, check the health plans website to see whether the evidence of coverage is posted. Many health plans do not provide the Evidence of Coverage documents until you have purchased a health plan and are a paid member. However, if you need to know whether a health plan covers benefits you need, you can try asking for the EOC document from the plan before enrolling. You might find that it can be difficult to get the EOC, though, before you enroll in the plan.

We will be researching whether some states have laws that require some health plans to make the EOC available to people who are considering purchasing a plan, but this will vary depending on the state. For instance, California requires health plans to provide EEOC upon request.* If you cannot get the EOC through the plan, you should consider contacting your state’s department of insurance to learn if the state requires health plans to provide the EOC on request. If your state requires the plans to make the EOC available on request, then you should formerly request it from the plans whose policies you are considering.

Q3. What information can I get from the EOC?

A. The EOC provides information on payment (premiums, deductibles, copayments, coinsurance) eligibility, enrollment, and how to get services. It will also explain how to get services as well as the plan’s policy on benefits and cost sharing, including limitations. For example, a managed care health plan might require that you receive services only from Plan Providers. The EOC will also explain what services are not covered and any deductibles, copayments, and coinsurance you must pay, if any, for each covered service. For example, the plan might provide vaccines and tests used to identify disease such as mammograms, for free. It might charge a $30 copayment per day for inpatient physical, occupational, or speech therapy provided in a rehabilitation setting while not covering eyeglasses at all. It will also explain how much cost sharing the plan requires. This means how much money you must pay out of pocket every year until you reach the annual limit. The EOC will also explain how to file a grievance or appeal if you disagree with the plan’s decision about your care. In some states, a grievance is simply a complaint that service wasn’t good, rather than a request for review of a denial of coverage.

Q4. What can I do if the EOC does not provide the information I need?

A. In some cases, the EOC might refer you to member services for more information. If you live in a state that requires the plan to provide the EOC to you on request, then it is possible that member services will also be required to answer your questions. It is also possible that you will not be able to get this information before you purchase a plan.

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* Section (6)(A)(i) of California’s 1975 Knox-Keene Health Care Service Plan Act as amended requires that managed care health plans’ disclosure form state that the Evidence of Coverage discloses the terms and conditions of coverage, and Section (6)(A)(ii) requires that the disclosure form state that the applicant has a right to view the Evidence of Coverage prior to enrollment and also specifies where the Evidence of Coverage can be obtained prior to enrollment.