The document that describes the benefits and services that are covered under an HMO's health care plan is called "Evidence of Coverage (EOC)."
An HMO's EOC must be approved by the commissioner prior to being offered by the HMO, must contain a clear and complete statement of the Plan's benefits and limitations, information about obtaining services and information about complaints and appeals.
For a complete listing of the provisions which are mandatory for an HMO EOC, view the governing rule.
The specific benefits and services that an EOC must cover depend on the type of HMO, the size of the covered group, the type of health care plan which the EOC describes. An HMO's health care plan may cover:
- An individual, a small employer group (2-50 employees) or a large employer group (51 or more employees)
- "State-mandated" benefits or "consumer choice" benefits
- "Basic health care services," or "Limited Health care services," or a "Single health care service"
View the available HMO EOC checklists.