It details the services that will and will not be covered. Services that are not covered are called exclusions . The certificate outlines your obligations. It is important to keep the certificate available, because it should be the first place you look when you have a question about coverage. It includes the phone numbers to call if you have any questions, including the number for the HMO s customer representative.
Every plan has a different certificate because the benefits under each plan are different.
To find out whether a specific service or supply is covered, look for the heading that applies to the situation. For example, if your child is brought to the hospital by an ambulance and then stays in the hospital as an inpatient, the coverage for the ambulance service may be different from the coverage for the hospital stay. You may be required to make a copayment for the ambulance service but not for the hospital stay. Certificates usually have a section of definitions to explain words that have special meanings. It is important that you use the definitions to best understand your coverage.