The fine print: Where to look for health insurance coverage details
It can be very helpful to know what your health plan covers. It can be even more important to understand what your plan doesn't cover.
Evidence of Coverage documents
Look for coverage guidance in the detailed document for your plan known as the plan booklet or Evidence of Coverage (EOC). EOCs are summaries of the contracts between insurance companies and the University of California. You will find a great deal of helpful information in your EOC, including information about coverage limitations and exclusions. For example, a common exclusion in health plan contracts is for care that isn't medically necessary.
View your EOC: you will find links to the UC Evidence of Coverage documents here.
Medical Guidelines
UC's contracts with insurance companies do not usually go into detail about coverage for the many and various types of medical procedures offered by health care professionals; there are simply too many to name, and new technologies and techniques are constantly being discovered and refined. However, to find out more about whether a particular procedure or service may be covered, it can be useful to scrutinize the Medical Guidelines that insurance companies use to make coverage decisions. Clinical Practice Guidelines illustrate the standards of care that insurance companies expect health care professionals to provide. Medical Policy and Utilization Management Guidelines offer a view of the rationale used by insurance companies to determine whether equipment, procedures or services are considered to be medically necessary, sometimes by citing relevant scientific literature. These guidelines can be difficult to understand as their target audience is health care professionals, but they can also be useful to patients who want to research their options.
View Medical Guidelines for the following plans:
