HMO Resources

Evidence of Coverage

The Evidence of Coverage is the binding document between a Health Maintenance Organization (HMO) and its members. The HMO’s Evidence of Coverage is sent to you at no charge when you enroll or can be obtained by calling the TBT Plan Administration Office.

The HMO’s health plan physician must determine that the services and supplies are medically necessary to prevent, diagnose or treat your medical condition.

If you have coverage through an HMO offered by TBT, the services and supplies must be provided, prescribed, authorized or directed by the HMO’s health plan physician. You must receive the services and supplies at an HMO health plan facility or skilled nursing facility within the HMO’s service area, except where specifically noted to the contrary in the HMO’s Evidence of Coverage. For details on the HMO’s benefit and claims review and decision procedures, refer to the HMO’s Evidence of Coverage. To get more information about your HMO options through TBT, call the TBT Plan Administration Office.

HMO Service Areas

Some HMOs offered by TBT provide zip code lists to show the ZIP+4 codes that are within specific counties in their service areas. Keep in mind that the HMO service areas may change. If you have questions about whether a ZIP+4 code falls within the HMO’s service area, it’s best to call the HMO directly at the number shown on the Contact page.

Here is a sample zip code listing for the Kaiser HMO (PDF).

Questions?

For details on the HMO’s benefit and claims review and decision procedures, refer to the HMO’s Evidence of Coverage. To get more information about your HMO options through TBT, call the TBT Plan Administration Office.

Comparison of Medical Benefits

See the Comparison of Medical Benefits for your TBT Plan to select your TBT medical plan option. It shows how the options compare and explains important features such as the Blue Cross PPO network. You can also consult your Summary of Coverage for details about benefits under your TBT Plan.

The Comparison of Medical Benefits is a summary only. It does not fully describe your TBT medical benefits. If you have coverage through the HMO offered by TBT, these benefits are explained in separate materials from the HMO. For details on the HMO, refer to your Plan’s Summary of Coverage and Comparison of Medical Benefits or each HMO’s Evidence of Coverage.