Using Health Plan Customer Services to Learn Scope of Coverage

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.

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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:

1. 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.
2. If the SBC does not provide the information you need, you will find a telephone number listed at the top of each SBC that you can call for additional information. These numbers are important because they connect you directly to plan representatives.

   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 Evidence of Coverage document (EOC), which describes in detail the health care benefits covered by the health plan. You can request the EOC document from the plan before enrolling, but sometimes it can be difficult to get before you actually join the plan. Some states have laws that require the EOC document to be made available upon request, but this will vary depending on the state. If you can’t get the EOC through the plan, you should consider contacting your state’s department of insurance to determine if your state allows you to obtain the EOC before you enroll in a plan. If your state requires plans to make the EOC available, then you should formerly request it from the plans you are considering.

In some cases, however, even the EOC document 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 EOC also might refer you back to member services for inquiries about specific items or services.

Q4. What should I do if a plan representative tells me that I must join the plan in order to have access to the specific and detailed information I need about covered benefits provided either in the EOC or by member services?

A. Some health plans will only provide information about specific benefits after you have entered into a coverage contract with that company. If your state does not require that plans make the EOC available on request, and you think the policy is a very strong contender for you based on what you have learned about it so far, then you should consider purchasing the plan. Once you have enrolled, you can contact your plan’s customer services phone number for detailed information about coverage.