Understand your benefits · Lesson 10 of 16
Where do I find the rules for my employer plan, Marketplace plan, Medicare, or Medicaid?
The short answer
Your plan's own documents hold the rules that apply to you. Start with the Summary of Benefits and Coverage. Employer plans also have a Summary Plan Description. Medicare and Medicaid have official websites and plan notices. When unsure, call the number on your card.
Key takeaways
- General articles, including this one, cannot replace your plan's documents.
- The Summary of Benefits and Coverage gives a short, standard overview.
- For full details, ask for the plan document or evidence of coverage.
Start with the short summary
Most plans must give you a Summary of Benefits and Coverage (SBC). It uses a standard format to show your deductible, copays, and examples of costs.[1] You can find it on your plan's website or ask for it.
Employer plans
Your employer plan has a Summary Plan Description (SPD). It explains benefits, how to file claims, and how to appeal.[2] Ask your HR or benefits office, or the plan administrator, for a copy.
Marketplace plans
If you bought your plan through HealthCare.gov or a state Marketplace, your plan's SBC and policy are on the insurer's website. Your Marketplace account holds eligibility and enrollment notices.
Medicare
Medicare rules are on Medicare.gov.[3] Original Medicare sends a Medicare Summary Notice. Medicare Advantage and drug plans send an Evidence of Coverage and an Annual Notice of Change each fall. Free counseling is available through your State Health Insurance Assistance Program (SHIP).
Medicaid and CHIP
Medicaid and CHIP are run by each state, within federal rules.[4] Your state Medicaid agency website and member handbook explain your benefits. If you are in a Medicaid managed care plan, that plan also has a handbook.
Who to call
Use the member services number on your insurance card. Ask for answers in writing when a decision matters, or write down the name, date, and reference number.
What can be different for you
Self-funded employer plans follow federal rules; fully insured plans also follow state insurance rules. Government and church plans may follow different rules. Medicaid benefits, names, and phone numbers differ by state. Your plan type is often listed on your card or SBC.
More detail (optional)
Not sure what kind of plan you have?
Look at your insurance card and recent EOB. Ask your employer whether the plan is self-funded or fully insured. This affects which agency oversees it and which appeal rules apply.
Where to complain
Your state insurance department oversees many insurance companies. The U.S. Department of Labor helps with most private job-based plans. Our complaint guide shows who handles which problem. A complaint does not replace an appeal, so still appeal by the deadline on your notice.
Words in this lesson
- Summary of Benefits and Coverage (SBC)
- A standard, short summary of a plan's costs and coverage that most plans must provide.
- Summary Plan Description (SPD)
- A document for employer plans that explains benefits, rights, and how to file claims and appeals.
- Health Insurance Marketplace
- The government-run place to compare and buy individual health plans, such as HealthCare.gov or a state Marketplace.
- Medicare
- Federal health insurance for people 65 and older and for some younger people with disabilities or certain conditions.
- Medicaid and CHIP
- Public health coverage for people with limited income, and for children through CHIP. Each state runs its own program within federal rules.
Related
Where can I go for help?
Free help is often close by: the member services number on your insurance card, the billing office for your provider, your state insurance department, and nonprofit patient advocates.
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.