Understanding of Health Insurance Certificate of Coverage

If you register in a health insurance plan, a certificate of coverage is issued to you.  It is also called a contract, evidence of coverage, or SPD summary plan description (SPD). You can contact your insurance customer service department at any point of time, during your coverage and ask for a written copy of your certificate of coverage. This is provided free of charge.

This document makes clear the health benefits that you and your dependents come under the plan. It gives detailed descriptions of the services that you will get. The health insurance services that are not covered are called exclusions. The actions you have to take to receive the health benefits—such as paying a copay or capped contribution, meeting a deductible, or using particular healthcare providers—are called conditions or circumstances.

The health insurance certificate summarizes your obligations. It explains:

• When and how much you will be required to make co-payments and pay the deductible, both for network and non-network providers.
• When you will require to find a recommendation from one provider to another.
• When you will need to call the insurance company to obtain approval before you receive a service out-of-pocket maximum.
• Lifetime maximums for grandfathered plans (before ACA) or nonessential medical benefits.

The certificate of coverage of health insurance also details the procedure for appealing decisions made by the insurance company. It is essential to keep the certificate available because it is the first thing that you need to look at whenever a question about coverage comes. It includes the phone numbers of the insurance company and its representatives.

Every plan carries a separate certificate as the benefits under each plan are not the same. To find out whether a specific service or supply is covered, search for a suitable heading for the situation. Be sure to look up every service or supply that might apply for health insurance so you won’t have to be surprised. Extra payment for the ambulance service might be necessary, but it required no additional payment for the hospital stay.
Certificates usually have a section of definitions to explain the unusual meaning of words.