This fact sheet is intended to help Navigators answer specific questions that people with disabilities might ask about getting and using health plans’Member Handbook, Policy, or Contract documents when purchasers are considering buying health insurance through the Marketplace.*
Q1. What is Member Handbook, Policy, or Contract?
A. The Contract, or Policy is a document that describes in detail the health care benefits covered by the health plan. It may also be called a Member Handbook. It provides documentation of what that plan covers and how it works, including how much you pay and other rights.
See the New York specific fact sheet on “Summary of Benefits and Coverage (SBC).”
Q2. Can I get the Subscriber Agreement/Member Handbook for a plan I am considering buying?
A. First, check the health plan’s website to see whether the Member Handbook, Policy, or Contract is posted. If you need to know whether a health plan covers benefits you need, ask for the Member Handbook, Policy, or Contract from the plan before enrolling. Health plans will make these available to prospective enrollees upon request. They are sent to subscribers once they have paid their premiums. Model Contracts or Policies for standard plans are posted on the NY Dept. of Financial Services website here. If you are having difficulty getting a Member Handbook, Policy, or Contract before enrolling from an HMO plan, you can contact the NYSDOH Bureau of Consumer Services at 518.456.1429 for assistance. If you are having difficulty with a non-HMO plan, you can contact the Department of Financial Services at (212) 480-6400 or toll-free (800) 342-3736 (Monday through Friday, 8:30 AM to 4:30 PM). State law says that issuers have to make these documents available to prospective enrollees.
Q3. What information can I get from the Member Handbook, Policy or Contract?
A. The Member Handbook, Policy, or Contract 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, an individual plan through New York State of health will require that you receive services only from Plan Providers. The Member Handbook, Policy, or Contract 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 Member Handbook, Policy, or Contract will also explain how to file a grievance or appeal if you disagree with the plan’s decision about your care. A grievance is a complaint that service wasn’t good. An appeal is a request for review of a denial of coverage based on medical necessity.
Q4. What can I do if the Subscriber Agreement does not provide the information I need?
A. In some cases, the Subscriber Agreement might refer you to member services for more information. The plan should give you the information you are requesting. If you have difficulty getting information you need, contact the NYSDOH Bureau of Consumer Services at 518.456.1429 or the Department of Financial Services at (212) 480-6400 or toll-free (800) 342-3736 (Monday through Friday, 8:30 AM to 4:30 PM).
* Written for New York by Center for Independence of the Disabled, NY