Rant about Evidences of Coverage and US health insurance

So frustrated with US health insurance right now. Thanks to my mom’s passion for medicine, 30+ year career as a Registered Nurse, and general wonkery for navigating health insurance, I have made sure to request and review Evidences of Coverage (EOC) for each medical plan I’ve been able to choose from. The EOC is the reference document for exactly what is covered by the insurance and goes into excruciating detail over which procedures and medications are covered and when and at what rate.

An Evidence of Coverage is the most important document to review when making a choice about a health insurance plan in the US. And my employer has been waiting since open enrollment in November 2023 for Cigna to provide this document.

Cigna, and thus my employer, have provided me with a Summary of Benefits and Coverage (SBC), which is a heavily-summarized document based on the Evidence of Coverage that includes an explicit disclosure to refer to the Evidence of Coverage (because the SBC is just a summary).

In California, we have a set of consumer protection laws that govern what information must be made available to people prior to enrolling in a health insurance plan. They’re very similar in nature to the laws that govern information about other types of insurance: a consumer needs to know what they will receive for the premiums they will pay. California’s relevant laws for health insurance are found in the Health and Safety Code 1363, with the especially-relevant portion being (b)(6)(A) and (b)(6)(B):

(6) A statement that the disclosure form is a summary only, and that the plan contract itself should be consulted to determine governing contractual provisions. The first page of the disclosure form shall contain a notice that conforms with all of the following conditions:

(A) (i) States that the evidence of coverage discloses the terms and conditions of coverage.

(ii) States, with respect to individual plan contracts, small group plan contracts, and any other group plan contracts for which health care services are not negotiated, that the applicant has a right to view the evidence of coverage prior to enrollment, and, if the evidence of coverage is not combined with the disclosure form, the notice shall specify where the evidence of coverage can be obtained prior to enrollment.

(B) Includes a statement that the disclosure and the evidence of coverage should be read completely and carefully and that individuals with special health care needs should read carefully those sections that apply to them.

According to the information I’ve received about why I still do not have EOCs available over three months from when I first requested them, it’s claimed that (b)(6)(A)(ii) doesn’t apply because this is a “group plan contract for which health care services are negotiated.” And as far as I can make sense of the CA Health and Safety code, this is a loophole despite the obvious implication of (b)(6)(B) that requires a statement that “the evidence of coverage should be read completely and carefully.”

I know I’m in the minority in asking for EOCs during open enrollment. Every HR team I’ve interacted with for the last 20 years has questioned my request for these documents. Most employees making health insurance decisions don’t know these documents exist or why they’re important to know about. I’m so frustrated with health care in this country. It’s so bad, it’s so expensive, and it enriches a small few at the direct detriment of millions of people. 🤬

Update as of March 4, 2024

My over-the-weekend request finally resulted in the delivery of Evidences of Coverage. Now to review four ~120 page insurance documents…