Transparency in Coverage

Welcome to Rocket Health, a health plan designed to be transparent. We are excited that You have chosen Us and want You to understand the ideas, words, and documents that You may read when You use this product. Our innovative approach to health insurance is intended to empower You to make health care decisions without network restrictions and to be fully informed of the benefits payable by this plan.

In the following paragraphs, Rocket Health and its affiliates are referred to as “We” or “Us” and Our members and their enrolled dependents are referred to as “You."

Out-of-Network Liability and Balance Billing

Rocket Health does not use a provider network.

Rocket Health’s plans do not use a network of preferred or contracted providers. You can receive medical services and prescription drugs from any licensed provider, including any pharmacy or healthcare provider.

The plan pays a Benefit Amount for each covered service.

This plan will pay the "Benefit Amount" for each covered service. Until Your deductible is met, the Benefit Amount for each covered service is applied to Your deductible. There is no deductible for preventive care. After Your deductible is met, the plan pays You the Benefit Amount for each covered service. The Benefit Amount will be the same for any provider regardless of what the provider charges.

You can view the Benefit Amount for each covered service.

You may view the Benefit Amount for each covered service on Our website.

You are responsible for the difference between the Benefit Amount and the provider’s charge.

You are responsible for any amount charged by a provider in excess of the Benefit Amount. The plan pays the Benefit Amount even if it exceeds the provider’s charge.

You can use the cost estimator tool to view the Benefit Amount for each prescription drug or healthcare service and see what providers have charged other Rocket Health members for such care. You are encouraged to call providers before seeking services. You can ask the provider for their cash price for care.

Providers may bill You if they charge an amount greater than the Benefit Amount. We pay the Benefit Amount.

Grace Periods and Claims Pending

In general, Your payment for each month of coverage is due on the first day of that month. After You make Your first premium payment, if You fail to make a premium payment by the due date, You will be granted a grace period.

A grace period is a designated period of time immediately following the due date of Your monthly premium during which You have the opportunity to pay Your delinquent bill without losing Your health care benefits. If Your premium is paid during the grace period, coverage will remain in effect. If Your premium is not paid during the grace period, coverage will terminate as explained below.

Standard Grace Period

After You make Your first premium payment, there is a grace period of 30 days during which to make Your past-due premium payment if You fail to pay Your premium by the due date. During the grace period, Your health care coverage remains in force. If Your premium is not paid by the end of the grace period, Your coverage will be cancelled after the last day of the grace period, and coverage will be terminated effective the day after the last day of paid coverage. You will be responsible for any expenses incurred during the grace period, and will be billed for any expenses paid by Us during that time, if You fail to make Your past-due premium payment.

Failure to timely pay premium payments is not a special open enrollment event for later coverage under the plan.

If Your coverage is terminated for not paying Your premium, and You request reinstatement, all past due and current premium must be paid in full to be reinstated.

Retroactive Denials

If You are found to be no longer eligible for coverage by Rocket Health, a claim may be “reversed” (reprocessed and denied retroactively, even after it has been paid), meaning that You become fully responsible for payment to the provider. In most cases, You can prevent a retroactive denial by paying Your premiums on time and by promptly notifying Us or (if applicable) Your marketplace of changes in Your eligibility status.

Recoupment of Overpayments by You

If You believe that We have overbilled You for Your premium, or made any other error in billing or payment, please contact us at 1-877-653-6440.

Medical Necessity and Prior Authorization and Enrollee Responsibilities

We rely on Medical Necessity.

We pay claims in accordance with the plan documents, including whether the services received by You were Medically Necessary. We will determine Medical Necessity upon receipt of Your Medical Invoice for a covered service. In some cases, We may require Your medical records to determine Medical Necessity.

The fact that a provider may prescribe, order, recommend or approve a service, treatment, or supply does not make it Medically Necessary or a covered service and does not guarantee the payment of a Benefit Amount.

If You use Your Benefit Card prior to submitting a Medical Invoice to Us, We will determine Medical Necessity of the covered service upon receipt and inform You if We determine that the service was not Medically Necessary. In such event, We will deny the claim and You will have the right to appeal Our determination.

We do not use prior authorization.

Our plans do not require prior authorization for any covered service.

We require pre-approval for certain Benefit Card transactions.

The Benefit Card can be used to pay for covered services at the point-of-service or point-of-care, up to the Swipe Limit.

To use the Benefit Card to pay for a covered service that exceeds the Swipe Limit, You must obtain Our prior approval for such transaction. To request pre-approval, submit to Us a provider’s pre-bill or such other evidence that is equivalent to a Medical Invoice.

To obtain pre-approval for use of the Benefit Card to pay for a covered service that exceeds the Swipe Limit, contact Us by telephone at 1-877-653-6440. The Swipe Limit is stated in Your plan’s Schedule of Benefits.

Pre-approval of use of the Benefit Card does not guarantee benefits.

Our pre-approval to use the Benefit Card for an amount that exceeds the Swipe Limit does not guarantee either payment of benefits or the amount of benefits. Eligibility for, and payment of, benefits are subject to all terms and conditions of the Policy.

Drug Exception Timeframes and Enrollee Responsibilities

This plan does not use a prescription drug formulary. To view the Benefit Amount for any particular FDA-approved prescription drug, You may visit Our website.

Explanation of Benefits (EOBs)

An Explanation of Benefits (EOB) is a statement that We will send to You after We adjudicate Your claim. The EOB is not a bill. Instead, the EOB explains the Benefit Amount payable by the plan for each covered service You receive and any financial responsibility that You bear (which You may owe to Us). The EOB also provides You with information about Your appeal rights if You disagree with how We processed the claim(s).

Coordination of Benefits (COBs)

If You are enrolled in more than one health insurance plan, those plans work together through a process called “coordination of benefits” to make sure You get the most from Your coverage. One plan is designated as Your primary plan and pays Your claims according to its rules, Your secondary plan then pays toward the remaining cost according to its rules, and so on. This process prevents duplication of payment across Your plans.