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 health insurance plan is best for me and my family?
If you don’t already have health insurance or if you’re interested in switching to a new health insurance plan, you may want to buy a plan on your own through the Affordable Care Act’s Health Insurance Marketplace. 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 so you can decide which one is best for you and your family.
You can find additional information on HealthCare.gov, the federal health insurance marketplace, and HealthSherpa.com, an online tool that 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. Resources from Consumer Reports and the National Association of Insurance Commissioners can help you understand how insurance works, insurance options and factors to consider when purchasing coverage.
What changes did the Affordable Care Act make?
The Affordable Care Act made it easier for people without health insurance or looking to switch health insurance plans to find quality, affordable insurance. All health plans sold through Healthcare.gov are offered by private insurance companies and are required to meet minimum requirements.
These 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.
How do I know if I’m eligible for an ACA plan and how can I enroll?
If you don’t already have health insurance or if you’re interested in switching to a new health insurance plan, you may want to buy a plan on your own through the ACA’s Health Insurance Marketplace. Individuals who need coverage and small employers with fewer than 50 full-time employees can purchase coverage through the Marketplace.
The plans sold on the marketplace must provide patient protections including the guarantee of coverage for pre-existing medical conditions and coverage of essential health benefits. In addition, most people qualify for financial assistance to help make their insurance premiums more affordable. The amount of financial assistance depends on income and family size. People 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.
People can enroll in a Marketplace plan NOW through Jan. 15, 2022. In certain circumstances, you may be able to buy coverage outside of the regular open enrollment period.
These circumstances include:
- having or adopting a baby
- getting married
- moving to a new state
- losing your health insurance coverage
Additionally, those who qualify can apply for the Children’s Health Insurance Program 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.
How does the ACA impact Medicare coverage?
Medicare beneficiaries receive some additional benefits as a result of the ACA, including an annual wellness exam at no cost, no cost-sharing for preventive services and increased discounts on prescription drugs. The ACA does not cut Medicare benefits, increase seniors’ out-of-pocket Medicare costs or deny seniors end-of-life care.
Under the Affordable Care Act, can I still get health coverage through my employer?
If you have health insurance through your employer, you can continue to get your health insurance through your job. However, if you are not satisfied you’re your job-based health insurance, you can shop for a plan on the ACA’s Health Insurance Marketplace. Generally, a quality health insurance plan will cost less through your employer than if you buy one on your own.
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” or "surprise billing"?
Some states allow health care providers that aren’t part of your plan’s network or don’t have a contractual agreement with your health plan to charge you if your insurance company won’t cover the full cost of care. This is called “balance billing” or “surprise billing”.
It’s very important to ask providers if they participate in your health plan, especially if you’re visiting a doctor, specialist or lab for the first time. In-network providers agree to accept your health plan’s payment, called the allowed amount, and not to bill you for the balance of the charge. This is an important benefit of using providers in your health plan’s network.
Surprise bills can cost hundreds, thousands or even tens of thousands of dollars, and they can bring severe financial hardship to patients. The American Heart Association is urging Congress to protect patients by ending surprise medical bills. To show your support, become an advocate with our You’re the Cure national grassroots 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 even if a particular health care provider or hospital is not in your insurance plan’s network. In addition, your plan can’t charge you a copayment or coinsurance on emergency services provided out-of-network that is greater than what it would charge if the services were provided in-network. However, in some states that allow balance or surprise 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.
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.
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.