Understanding the ins and outs of health insurance can be complicated but taking the time to educate yourself can help your health and your wallet. Here are some frequently asked questions to help you make the best decisions about coverage for you and your family.
How do I know which plan is best for me and my family?
Start by learning how health insurance works. Make a list of questions before you choose a health plan. Gather information about your household income and set your budget for health insurance. Learn the difference between different types of plans (like PPO, HMO and POS) so you can decide which one is best for you and your family. You can find additional resources on Healthcare.gov as well as through resources like HealthSherpa, an online tool that only offers comprehensive health coverage.
Find out if you can stay with your current doctors, hospitals and pharmacy. Learn common insurance terms, especially the ones that describe your share of the costs, such as deductibles, out-of-pocket maximums and co-payments. There are a number of resources from the Kaiser Family Foundation, Consumer Reports, the National Association of Insurance Commissioners and the U.S. Department of Health and Human Services to help you understand how insurance works, insurance options and factors to consider when purchasing coverage.
What changes did the Affordable Care Act (ACA) make to the law?
The Affordable Care Act or ACA made several significant changes to the laws that control what insurance companies can and cannot do when selling health insurance. All health plans sold through the Marketplace are offered by private insurance companies and are required to meet minimum requirements, these are known as ACA compliant plans. ACA compliant plans are required to cover a comprehensive set of benefits including hospital care, doctor visits, emergency care, prescription drugs, lab services, preventive care and rehabilitative services. Insurers are not allowed to charge more or discriminate against people based on health status, health history or gender. The ACA also allowed children to stay on their parents’ insurance until age 26. You can learn more about enrolling in an ACA compliant plan at HealthSherpa or Healthcare.gov.
How do I know if I’m eligible for an ACA plan and where to enroll?
Individuals who need coverage who are legally residing in the U.S. and who are not incarcerated are eligible to purchase coverage through their state’s Marketplace. Small employers with fewer than 50 full-time employees can also purchase coverage through the Marketplace. Insurance companies are not allowed to deny coverage to individuals with pre-existing medical conditions nor are they allowed to charge higher premiums to people because of their health status. Further, most uninsured individuals qualify for financial assistance called a Health Insurance Premium Tax Credit to help make their insurance premiums affordable. The amount of financial assistance depends on income and family size. Individuals with low incomes may qualify for free or very low premiums. To find out how much financial assistance you may qualify for, check out the Kaiser Family Foundation’s subsidy calculator.
The next open enrollment period begins Nov. 1 and ends Dec. 15 in most states. In certain circumstances, you may be able to buy coverage outside of the regular open enrollment period, such as if you:
- have or adopt a baby
- get married
- move to a new state
- lose your other health insurance coverage
Additionally, those who qualify can apply for the Children’s Health Insurance Program (CHIP) or Medicaid at any point during the year. There is no open enrollment period for these programs. Also, if you own or operate a small business, you can begin offering coverage to employees at any time.
If I’m having problems with my insurance, where can I file a complaint?
If you’re not satisfied with your health plan’s services or if your claim has been denied, call the member services phone number on your health plan member card. You may be able to resolve your concern over the phone, or you or your representative can file a complaint with the health plan.
If you decide to file a complaint, you may need to complete a form and submit it in writing so the health plan can investigate the facts, decide what to do and share any action being taken to address your complaint. You should receive a letter that explains how your complaint was resolved. It will include your appeal rights and how to submit an appeal if you want the health plan to reconsider its decision.
If you’re not satisfied with how your insurance company addresses your complaint, every state has an insurance department to help with questions or complaints. To find out more, contact your state insurance department. Ask if your state has a consumer assistance program that can help you file an appeal. The National Patient Advocate Foundation may be able to help you file an appeal or resolve billing or other complaints with your insurance company. You can also call them at (800) 532-5274.
What rights do I have if my insurance company denies coverage for a service?
You have the right to ask your plan to reconsider its decision. If your plan still denies payment after considering your appeal, the law permits you to have an independent review organization decide whether to uphold or overturn the plan’s decision. This final check is often referred to as an external review.
If you’re not satisfied with the way your insurance company addresses your appeal or if you need help, every state has an insurance department you can contact about your coverage. To find out more, contact your state insurance department. Your state may also have a consumer assistance program that can help you file an appeal. Ask your state insurance department if your state has such a program. Finally, contact the National Patient Advocate Foundation on their website or (800) 532-5274, may also be able to help you file an appeal with your insurance company.
What are out-of-network services and do I have any coverage for them?
Out-of-network services are services provided by a doctor, hospital or other provider that does not have a contractual relationship with your health plan. Not all plans cover out-of-network services, but if they do, your share of the cost is usually significantly higher than if the service was provided in network. For example, an HMO plan may not provide any coverage for out-of-network services, except in an emergency. When possible, try to learn whether the doctor or hospital you are visiting is in-network before receiving services.
What is “balance billing”?
Some states allow health care providers to charge you the difference between what the provider charges and what the insurance company has paid if you seek services from a provider that isn’t part of your plan’s network or doesn’t have a contractual agreement with your health plan. This is called “balance billing” and you are responsible for paying this amount.
It’s very important to ask providers whether they participate in your health plan, especially if you’re visiting a doctor, specialist or lab for the first time. Participating and preferred providers have agreed to accept your health plan’s payment, called the allowed amount, as payment in full and they have agreed not to bill you for the balance of the charge. This is an important benefit of using providers in your health plan’s network.
Is my health plan required to cover emergency care even if it’s out-of-network?
Yes. Federal law requires any health plan providing benefits for emergency services to cover them without regard to whether a particular health care provider or hospital is an in-network provider. In addition, the plan can’t impose any copayment or coinsurance on emergency services provided out-of-network that’s greater than what would be imposed if the services were provided in network. However, in some states that permit balance billing, an out-of-network provider can charge you the difference between what the insurance company has paid and what the provider has charged. In this case, you may face higher out-of-pocket costs for emergency care.
I get my health insurance through my employer. Under the ACA, does my employer still provide my insurance coverage?
If you have health insurance through your employer, you will probably continue to get your health insurance through your job. Although there has never been a legal requirement that employers offer coverage to their workers, there are numerous reasons many employers provide health insurance today (tax advantages, employee demand, maintaining a healthy workforce). In addition, large employers that don’t provide coverage may be penalized if their employees end up receiving financial assistance to purchase coverage through the new health insurance marketplaces.
I have Medicare. Did Medicare coverage change under the ACA?
You will continue to be covered through the Medicare program. The new law does not cut Medicare benefits or increase seniors’ out-of-pocket Medicare costs or deny seniors end-of-life care. Medicare beneficiaries are already receiving some additional benefits as a result of the law. They include an annual wellness exam at no cost, no cost-sharing for preventive services and increased discounts on prescription drugs.