If you are new to having health insurance (or even if you’re not so new!), you may find yourself trying to make sense of the documents sent to you by your carrier.
Here are a few of the documents you may receive:
Insurance Card or Other Proof of Coverage
This card or other document serves as proof of your insurance coverage. Some plans issue wallet-sized cards, while others provide the same information in another format. Some carriers provide an app that you can download on your cellphone to access your ID card. Either way, you should bring your proof of insurance the first time you visit a doctor, pharmacy, hospital, or other provider.
Look for some if not all of the following information:
- Your Name (Member Name) and Date of Birth
- Your Member Number — used to identify you for billing purposes. If your spouse or children are on your plan, their member numbers may be the same or similar to your own.
- Group Number — identifies the specific benefits of your plan.
- Plan Type — e.g., HMO, PPO, HSA (click here for more information on plan types)
- Effective Date of Coverage
- Applicable Deductibles
- Applicable out-of-pocket maximum limits
- Co-Pay amounts for various services — e.g., Primary Care Provider, Specialist, Emergency Room — this is the amount you will owe when you get health care.
- Prescription Group # and Co-Pay — Information about your prescription benefit including your group # and the amount you will owe for each prescription you fill. A different co-pay may be specified for generic vs. brand name medications.
- A Phone Number and Website where you can get help with questions about your coverage, finding a provider, or other information.
Summary Plan Description
This is a detailed explanation of the ins and outs of your coverage. It outlines the policy rules, the medical services covered by your insurer, the necessary fees you must pay (co-pays, deductibles, co-insurance), as well as listing services that are NOT covered by your plan.
It is important to read through your plan’s Summary Plan Description so you have a complete understanding of your coverage.
Explanation of Benefits (EOB)
You will receive an Explanation of Benefits (EOB) from your health insurance carrier each time you see a provider or receive a medical service. Some carriers will give you the option to choose email or regular mail for delivery of your EOBs. You can also access your EOBs through your app, if you have one.
An EOB is not a bill.
It is a record of health care you or others included on your policy received and how much the provider (doctor, hospital, clinic, etc.) is charging your health plan for that care. If you owe more money than your plan paid, your provider will send you a separate bill.
For More Information
You can visit your carrier’s website or app for more detailed information.
If you got your insurance through your employer, you can also check in with your company’s Human Resource (HR) or Benefits Manager.
If we helped you purchase your insurance, you can always contact us for help understanding your coverage. By phone: 703-707-8270 or by email: email@example.com.