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Every fall, millions of us sit down with a stack of plan summaries and try to make one of the most important medical and financial decisions of the year in a single evening: selecting healthcare insurance for our families or employees.

I did it for my own family, and I wrote about it in the first issue. I could compare deductibles and copays without much trouble, but I couldn’t tell what would happen if someone in my family got seriously sick, which is really the only question that matters when you’re choosing coverage.

Since then, I’ve been trying to find where that information actually lives. Some of it does exist, but it’s spread across separate documents, websites, and federal data files, and almost nobody tells you where to go looking for them. So this week I want to walk through what each of those sources shows, what it leaves out, and what you can ask for before you sign up. This isn’t advice about which plan to choose. It’s a map of where the details live, because I don’t believe we can fix a system we can’t see.

Every plan has to give you a Summary of Benefits and Coverage, usually called the SBC. This is the standard form we are all used to that insurers and employer plans have to use. This document discusses deductibles, out-of-pocket max, coverage limits, and in- and out-of-network benefits. This document also has to be written in plain language so you can compare plans side by side. [1] I was surprised to find out that this has really only been standardized for a little over a decade. Obviously, it was a great step forward when it arrived, and it’s still the first thing I’d recommend anyone read and understand. Under federal rules, an insurer can send you this summary up to seven business days after you apply, so if you don’t ask for it while you’re shopping, you may not see it until after you’ve already chosen. [2]

In my view, one of the most useful parts is near the end. This is the list of services the plan doesn’t cover at all, and there should be “coverage examples” that estimate what you might pay in a few common situations. Today those examples are having a baby, managing type 2 diabetes, and a simple fracture. [3]

When I looked into the history of this format of information, one thing that surprised me was related to breast cancer coverage. When regulators first proposed the form in 2011, there were three coverage examples, and one of them was treating breast cancer, which the state insurance regulators had recommended. [4][5] By the time the final rule came out in 2012, the breast cancer example was gone. The insurance industry had argued that the calculations would be too costly and complicated, and a federal official explained that breast cancer treatment isn’t standardized, so it was harder to turn into a single example. [5][6] Even the diabetes example was narrowed to someone whose condition is well controlled. [7] The rule allows up to six examples, and cancer advocates asked again in 2016 for the breast cancer example to come back, but the only one ever added was a simple fracture. [6][8] I understand why complicated examples can be difficult to understand on forms like this, but at the same time, serious illness is exactly what families most need help comparing plans for.

Even the people who hand these forms out are careful about what they can do. New York State’s employee benefits office answers the question “Should I use the Summary of Benefits and Coverage to decide which option is best for my family?” with one word: “No.” [9] So then my question is still how do we all

If you buy your own coverage on HealthCare.gov, or your employer gives you money to buy it there through an ICHRA as mine does, there’s data most people have never heard of. Insurers selling on HealthCare.gov have to report how many claims they received and how many they denied, and KFF, a nonprofit health policy research group, analyzes it every year.

In 2024, those insurers denied 19% of in-network claims, and the rate ranged from 3% to 36% depending on the insurer. [10] That’s an enormous spread for plans that can look almost identical on the summary.

I expected gold plans to deny fewer claims than bronze plans, since you pay more for them. They didn’t. The denial rates were nearly the same at every plan level, which I show below. [10]

Of course, the data has limits. It covers an insurer’s marketplace plans as a whole rather than your exact plan, and it’s a couple of years old by the time you see it. The reasons are vague, too: the most common reason listed was simply “other,” while 9% of denials were for missing prior authorization and 5% were for lack of medical necessity. [10] It also leaves out prior authorization requests that were turned down before any care happened. [10]

My thoughts on this are often: how clear is it to physicians which diagnoses are medically necessary for a service, and then how does this tie back to evidence-based guidelines?

When insurers deny a claim, the most common reason they give is “other.”

That last gap is finally starting to close. As of March 31, 2026, insurers selling on the federal marketplace, along with Medicare Advantage and Medicaid plans, have to post their prior authorization numbers on their own websites every year. [11] When KFF looked at the first reports from the largest insurers, marketplace insurers had denied 18% of standard prior authorization requests in 2025. [12] I’m going to spend a full issue on those reports soon, because they’re the first real look at a process that’s been hidden for a very long time.

If your coverage comes through a traditional employer plan, you won’t find either of these numbers for your plan, because employer plans don’t have to report them. That gap is a big part of why I started Gavari.

Every plan has a drug list, sometimes called a formulary, that shows which drugs are covered and at what level. Search it for each medication your family takes, and look for notes saying a drug needs prior authorization or step therapy, which means the plan wants you to try a cheaper drug first before it will cover the one your doctor chose.

But you can only search for the drugs you already know you need, and nobody searches for the drug they’ll be prescribed after a diagnosis they haven’t had yet.

Many insurers post their medical policies and their lists of services that need prior authorization on their websites. These are the documents that actually decide whether a test, a scan, or a surgery gets covered. If someone in your family has a condition, a planned surgery, or ongoing treatment, look up the policy for that specific service at each insurer you’re considering.

In my experience, these policies are long, written for doctors and lawyers, and different at every company. They also aren’t the contract itself, and per my understanding, they can change after you enroll. Even so, reading the one or two policies that matter most to your family will tell you more than any summary will. At least today, you could download them and have AI help you.

When I pulled up the summary for the plan my family chose, the phrase “no benefits if not preapproved” appeared again and again, next to imaging, hospital stays, home health care, medical equipment, and more. For drugs, it said some “may require prior approval.” Nowhere did it say which ones, or what the plan would need to see to approve them.

After all of this, I kept coming back to a basic question: if plans can differ this much, is there any minimum a plan has to meet? There is, but it stops at the category level. Plans sold to individuals and small businesses have to cover ten categories of “essential health benefits,” including hospitalization, maternity care, emergency services, prescription drugs, and lab services. Even that floor varies from state to state, because each state picks a benchmark plan that defines what those categories include. [13] Large employer plans and self-funded plans, which cover most workers with job-based coverage, aren’t required to cover these categories at all, although most do, and they can’t put annual or lifetime dollar limits on the ones they cover. [14] Nearly every plan also has to cover recommended preventive care at no cost to you, a rule the Supreme Court upheld in 2025. [15]

What none of these rules set is a minimum for how a plan decides what qualifies inside a category. My plan covers hospital stays, and it also says “no benefits if not preapproved.” The law makes sure the category is there, but it doesn’t say what the plan has to see before it says yes, and that’s what makes plans so hard to compare.

Insurers would say, fairly, that a short standard summary is exactly what consumers asked for, and that packing every medical policy into a comparison form would make it so long that nobody would read it or likely understand it. They’d also point out that a denial rate on its own doesn’t tell you whether a denial was right, since a quarter of marketplace denials in 2024 were listed as administrative, which can include things like paperwork problems (e.g., eligibility). [10]

I agree with both. My view is that the answer isn’t more pages. It’s an expectation that the minimum standards go a step further than just naming the category and actually make sure that patients have what they need in case of a complex diagnosis. And if the payers have to price accordingly, fine. At least we would know what to expect.

Before you pick a plan, call the insurer or ask your HR team: “Can you send me the prior authorization list and the medical policy for the service my family is most likely to need?” If nobody can send it to you, that tells you something too. But the general public is going to struggle with this level of detail.

Next week I want to talk about the phrase that sits behind so many coverage decisions: medical necessity. Who decides what’s medically necessary, what rules do they use, and why can’t patients, or sometimes even their doctors, read those rules? As a physician, this is the part of the system that bothers me most, and I think it’s where physicians have the most to offer.

If you’ve tried to track down any of these documents, reply and tell me how it went.

Gavari does not take money from health insurers or health plans. If an issue has a sponsor, it is labeled at the top.

This is general education about how health coverage works. It is not insurance, legal, or medical advice. I do not sell insurance or recommend plans.

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