This fact sheet is intended to help Navigators answer specific questions that people with disabilities might ask about the role health plan customer services can play when purchasers are considering buying health insurance through the Marketplace.*
Click here for a pdf version of this Fact Sheet
Q1. What are the primary purposes of health plan customer service?
A. Typically, health plan customer services can involve, as examples: checking a claim on behalf of a member, finding out whether a procedure, medication or service is covered and at what cost, and directing members to additional resources. Other services might involve registered nurses or other clinicians who provide advice and answer questions. In either case, interactions with members can take place by telephone, online and on mobile devices. Some health plans also operate retail storefronts where trained staff answers questions on the spot.
Q2. How do I get detailed information about the scope of coverage for services such as physical, occupational or speech therapy or for specific items of durable medical equipment (DME) from plans I am considering?
A. You can get information on the scope of coverage in two ways:
- All individual and group health plans participating in the Marketplace must use the same standard form, called “Summary of Benefits and Coverage (SBC).” The SBC is an easy-to-understand, plain language summary about a health plan’s benefits and coverage. Plans offered outside the Marketplace either through an employer or as individual coverage must also use the same standard form SBC.
- If the SBC does not provide the information you need, you will find a telephone number listed at the end of each SBC that you can call for additional information. These numbers are important because they connect you directly to plan representatives. (See also “Health Plan Customer Service Phone Numbers and Provider Networks” here.
You should reach a customer service representative who either will try to answer your questions or refer you to someone else who can. The representative might refer you to a sales representative since you are not a member of the plan and are seeking information about available coverage.
Q3. What should I do if neither the plan representative nor sales agent can provide the specific information about covered benefits that I need?
A. Some of the information you need might be available through the Member Handbook, Policy, or Contract, which describes in detail the health care benefits covered by the health plan. You can request this document from the plan before enrolling. New York requires that this document be made available to prospective enrollees upon request. If you have difficulty getting it from the plan, 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) for assistance.
In some cases, however, even the Member Handbook, Policy, or Contract will not provide the detailed information you require. For example, it might list general categories of covered DME such as blood glucose monitors and insulin pumps, but information might not be available about whether or not the specific item that you need is covered. The Member Handbook, Policy, or Contract also might refer you back to member services for inquiries about specific items or services.
* Written for New York by Center for Independence of the Disabled, NY
