The clauses behind your coverage.

Last updated August 17, 2026

My Live Health is an insurance agency, not an insurance company, so we do not write these provisions and we cannot waive them. What follows describes how these clauses usually work across the plans we help people compare. Your own plan documents are the ones that apply to you, and where they differ from this page, they control.

Where your provisions live

Every plan comes with a set of documents, and each one has a job:

• The summary of benefits and coverage is a short standardized document that lets you compare plans side by side. It is a summary, not the contract.
• The policy, certificate, or evidence of coverage is the contract. It contains the provisions described on this page, along with the definitions those provisions rely on.
• The schedule of benefits lists your deductible, copays, coinsurance, and out-of-pocket maximum.
• The provider directory and formulary list the doctors, facilities, and drugs the plan covers. Both change during the year.

If you cannot find these, your insurance company must give them to you on request, free of charge, in a format you can use. The health care glossary explains the terms they use.

Eligibility and enrollment

Eligibility provisions say who can be covered. Individual and family plans generally require that you live in the plan's service area and are not enrolled in Medicare. Plans through an employer add their own rules about hours worked and waiting periods. Medicare plans require that you have Medicare Part A and Part B and live in the plan's service area. Dependents are usually a spouse or domestic partner and children up to age 26.

Enrollment provisions say when you can join. Most individual coverage can only be bought during the annual Open Enrollment Period, or during a Special Enrollment Period triggered by a qualifying life event such as losing other coverage, moving, marriage, or the birth or adoption of a child. Special enrollment windows are short, usually 60 days, and usually require proof of the event.

Effective dates

Coverage does not start when you apply. It starts on the effective date stated by the plan, which normally depends on when your application was accepted and when the first premium was paid. Care you receive before that date is not covered, even if the application was already in progress.

Premiums and grace periods

Premium provisions set the amount, the due date, and what happens when a payment is late. Plans give you a grace period before coverage ends. Its length depends on the type of plan and on whether you receive an advance premium tax credit through the Marketplace, and the plan may hold or deny claims for care received during the later part of a grace period until you catch up.

If a payment is going to be late, call the insurance company before the due date rather than after. Coverage that terminates for non-payment can be difficult to reinstate, and losing coverage that way is generally not a qualifying event for a new special enrollment period.

Cost sharing

Cost sharing provisions divide the bill between you and the plan. The deductible is what you pay before most benefits begin. A copay is a fixed amount for a service, and coinsurance is a percentage. The out-of-pocket maximum caps what you can be required to pay for covered in-network care in a plan year, after which the plan pays 100 percent of covered services. Premiums, non-covered services, and balance bills from out-of-network providers do not count toward that cap.

Networks and referrals

Network provisions decide how much of the bill the plan pays based on which provider you use. In-network providers have agreed to contracted rates. Out-of-network providers have not, so the plan may pay less or nothing, and the provider may bill you for the difference. Some plan types require you to name a primary care physician and get a referral before you see a specialist. Others do not. Directories change during the year, so confirm network status with both the plan and the provider before an appointment.

Federal law limits surprise billing in specific situations, such as emergency care and some care delivered by out-of-network clinicians at an in-network facility. See the No Surprises Act page.

Prior authorization

Many plans require approval before certain services, procedures, or drugs are covered. If prior authorization is required and it is not obtained, the plan can deny the claim even when the care was appropriate. Providers usually handle these requests, but the responsibility for coverage falls on you, so it is worth confirming that an authorization is on file before a scheduled procedure.

Exclusions and limitations

Every plan has a list of things it does not cover and limits on things it covers only up to a point, such as a number of visits per year. Read this list before you enroll, because it is the single most common source of a bill people did not expect. Care that is considered experimental or investigational, and care the plan judges not medically necessary, are common exclusions and are also common subjects of appeals.

Pre-existing conditions

Major medical plans that comply with the Affordable Care Act cannot refuse you, charge you more, or exclude treatment because of a pre-existing condition, and they cannot impose annual or lifetime dollar limits on essential health benefits. Products that are not major medical coverage, such as short term plans and some supplemental products, can apply health questions, waiting periods, and pre-existing condition exclusions. Check which kind of product you are buying; the plan disclosures page explains the difference.

Coordination of benefits

When someone is covered by more than one plan, coordination of benefits provisions decide which plan pays first and which pays second, so the combined payment does not exceed the cost of care. This comes up with couples who each have coverage, children covered by both parents, and people who have both Medicare and another plan. Tell each plan about the other, because a claim can be delayed for months while the plans sort out the order.

Subrogation and recovery

If someone else is legally responsible for your injury, for example after a car accident, subrogation provisions let the plan recover what it paid out of any settlement you receive. Related provisions let a plan recover a payment it made in error. If you are pursuing a claim against another party, tell the plan and your attorney early, because these rights are usually asserted against the settlement itself.

Filing claims and deadlines

In-network providers normally file claims for you. When you have to file one yourself, the plan sets a deadline, and claims submitted after it can be denied for that reason alone. Plans also set deadlines for providing requested records. Keep bills, receipts, and explanations of benefits, and note the date you sent anything, because dates decide these disputes.

Appeals

If a claim or a service is denied, plan provisions give you the right to an internal appeal, with a defined window to file and a defined window for the plan to answer, and a faster track when a delay would put your health at risk. Once the internal process is finished, many plans and situations also carry a right to an independent review outside the plan. See filing a grievance or appeal and external review.

Continuation of coverage

If you lose employer coverage, federal COBRA rules or a comparable state continuation law may let you keep the same plan for a limited time by paying the full premium yourself. Continuation is usually far more expensive than it was through payroll, and there is a deadline to elect it. Compare it against an individual plan before you decide, because losing employer coverage also opens a special enrollment period.

Termination and non-renewal

Coverage can end because you cancel it, because premiums went unpaid past the grace period, because you no longer meet eligibility rules such as moving out of the service area, or because the plan is discontinued. Plans must give notice before discontinuing a product, and a discontinuation is a qualifying event that opens a special enrollment period so you can move to another plan.

Annual renewal and changes

Plans change every year. Premiums, deductibles, networks, and drug lists are all refiled for the new plan year, and a plan that fit you last year may not fit you this year. Read the annual notice of change your insurance company sends before Open Enrollment, and re-check that your doctors and prescriptions are still covered rather than letting the plan renew unexamined.