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Sample Evidence of Coverage

The Department of Managed Health Care collaborated with Health Research for Action at the University of California, Berkeley’s School of Public Health, on the development of a sample Evidence of Coverage (EOC) for large and small full service group health plans. The goal of this project was to provide health plans with language, formatting, and ideas to create group EOCs that meet Knox-Keene Act requirements while improving the readability and usability of documents through the implementation of health literacy principles.

The Sample EOC was developed solely for the purpose of providing guidance, in the form of one example, of easy-to-read and easy-to-understand EOC language. As discussed in Using the Sample EOC, the document was developed to be consistent with the Technical Assistance Guide for EOCs. Use of part or all of the sample may expedite the EOC review process, but all plans will continue to submit their EOCs and changes to the DMHC for review. The DMHC hopes that using the sample EOC language will ultimately simplify the development and review of EOCs. When a plan files an EOC, they may indicate on the E-1 that they are using the sample and redline any language changes that differ from the sample language. If sections of sample language are used in whole, the DMHC would approve that language provided the context in which it was used was appropriate.