Coverage and benefits
Understanding your health insurance benefits
Need to know if a medical procedure or service is covered? You’ll likely find the answer to your question in your Summary of Benefits and Coverage (SBC). An SBC is an overview of what your health plan benefits include. It lists common medical services, what your cost share may be and other important information.
For an in-depth, complete guide to everything your health plan includes or excludes, your Coverage Manual will have that information. It describes your plan’s specific coverage details and how your health plan works. If you have a question about a specific procedure or service, your Coverage Manual will explain how your health plan may cover it. Coverage Manuals also include information about your prescription drug benefits.
Both documents can be found by:
- Logging in to myWellmark Secure Site®.
- Searching our public SBC and Coverage Manual Finder using your Wellmark ID number.
- Calling the number on your Wellmark member ID card for assistance.
Common health insurance benefits
Each health plan’s coverage is a little different. For a complete list of your coverage and benefits, visit the Coverage tab in myWellmark® Secure Site or search for your coverage manual using your Wellmark ID.
Some benefits are covered across all plans. Here are some common services members have questions about:
Wellmark offers no-cost COVID-19 testing when it’s ordered by a health care provider and will reimburse members for FDA-approved over-the-counter COVID tests that were purchased after Jan. 15, 2022. Review the COVID FAQs for information on how to get reimbursed for approved at-home tests.
There are certain supplies and equipment that are necessary after surgery, pregnancy, or required for everyday use. Common types of durable medical equipment (DME)Glossary popover include:
- Wheelchairs
- Walkers
- Breast pumps
- Oxygen equipment
- Insulin pumps
These are covered by insurance when you get a prescription from your doctor. Once you have a prescription, check your coverage Secure Site in myWellmark® to see if there might be a copay or coinsurance for the DME. To find coverage for DME, look under “H” for Home/Durable Medical Equipment or check your coverage manual, which can be found in the Resources box.
Once you have that information, you can use Wellmark’s suppliers Better Living Now External Link or Edgepark External Link for your DME. Using an in-network DME provider is the simplest way to avoid unexpected costs and make sure you get the most from your benefits.
Like other pieces of durable medical equipment (DME), a breast pump is a covered benefit when you get a prescription from your OB or midwife. During one of your prenatal appointments, simply ask your health care provider for a prescription, then visit one of Wellmark’s suppliers Edgepark External Link or Better Living Now External Link to get your breast pump.
Depending on your health plan, you can receive all annual preventive visits for you and your dependents at no cost. The Affordable Care Act mandates that all non-grandfathered group and non-grandfathered individual health plans must provide preventive services at no member cost share, when delivered by an in-network health care provider.
Preventive services include: annual wellness exams, cancer screenings, well-child visits and immunizations, adult vaccinations and prenatal wellness checks. This is not an exhaustive list, so visit myWellmark Secure Site to view your coverage and benefits.
Authorization and approvals
Understand the authorization process and which procedure, service or admission needs an authorization.
Claims and appeals
Understand how a claim works, how to submit a claim, and how to make an appeal.
Explanation of Benefits (EOB)
See how your coverage is applied to claims.
Life events
Know which qualifying life events allow you to add or change your plan outside of annual enrollment period.
Medical policies
Review the guidelines used to determine coverage for specific medical technologies, procedures, equipment and services.
