What is an insurance plan document?
A health insurance plan document governs the terms of coverage for your specific health plan. A plan document can have many names such as Summary Plan Description, Member Handbook, Certificate of Coverage, Certificate of Insurance, or Exclusive Provider Organization Policy. It is a long document, 70 pages or more, and it will have a section listing services that are not covered (exclusions and limitations). Most are available as PDFs, but some are paper-only.
How do I get my insurance plan document?
Common ways to get your plan document include the following:
- Online - Login to your insurance company's website or your employer's benefits website and search there.
- Phone - Call the number on the back of your card and ask for it. Specify that you want the full plan that lists all of the exclusions, not just the Summary of Benefits and Coverage. They may tell you that only your employer can give you the booklet.
- Write - Email human resources and request the Summary Plan Description.
Is this my plan document?
The following things are not your plan document:
Generic clinical guidelines. Insurance companies have general criteria for when they will cover gender reassignment surgery. Those are known by many names such as a medical policy, clinical guideline, or clinical review criteria. This is a generic document that generally applies to all of the specific plans that insurance company administers. Although it is not your plan document, you will need this document. You can search for your insurance company's policy on the list we've compiled of gender reassignment coverage policies. If your insurance company's policy is not listed there, please let us know.
Summary of Benefits and Coverage. This is a chart that all health plans are required to provide. It lists things such as copays, co-insurance, and deductibles. It will give you an idea of how much you will have to pay out of pocket for care and the date on which out out-of-pocket maximum resets.
Benefits overview or open enrollment guide. Employers may provide a colorful document that describes the various benefits offered by the company. This will often include things other than health benefits, such as short-term disability benefits, life insurance, or dental benefits. If it lists multiple health plans to choose from, it is probably not your plan document.
Is my employer required to give me my plan document?
The Employee Retirement Income Security Act (ERISA) requires virtually all private employers to give you your plan documents, including the Summary Plan Description, if you request them in writing. They are subject to a $110/day fine if they do not provide it within 30 days. ERISA does not apply to government employers and certain religious employers.