Written by HummingbirdinsAdmin on . Posted in Frequently Asked Questions.
Under the health care law, dental insurance is treated differently for adults and children 18 and under.
Dental coverage for children is an essential health benefit. This means it must be available to you, either as a covered benefit under your health plan or as a free-standing plan. This is not the case for adults. Insurers don’t have to offer adult dental coverage.
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Health plans in the Marketplace must include a link to their prescription drug “formulary” with other on-line information about the plan. The “formulary” is a list of prescription drugs the plan will cover. If you don’t find your drug on the formulary but your doctor says it’s medically necessary for you to take that specific drug, you can appeal for an exception to the plan formulary. If there is a Consumer Assistance Program in your state, staff in this program can help you file your appeal.
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Plans are not required to cover any care received from a non-network provider, though many plans today do, at least to some extent. If you do receive care out of network, it could be costly to you. Generally plans that provide an out-of-network option cover such care at a lower rate (e.g., 80% of in-network costs might be reimbursed but only 60% of non-network care.) In addition, when you get care out of network, insurers may apply a separate deductible and are not required to apply your costs to the annual out-of-pocket limit on cost sharing. Non-network providers also are not contracted to limit their charges to an amount the insurer says is reasonable, so you might also owe “balance billing” expenses.
If you went out of network because you felt it was medically necessary to receive care from a specific professional or facility – for example, if you felt your plan’s network didn’t include providers able to provide the care you need – or if you inadvertently got non network care while hospitalized if the anesthesiologist or other physicians working in the hospital don’t participate in your plan network – you can appeal the insurer’s decision. If there is a Consumer Assistance Program in your state, staff in this program can help you file your appeal.
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Each plan sold in the Marketplace must provide a link on the Marketplace web site to its health provider directory so consumers can find out if their health providers are included.
The provider network information that insurance companies provide may or may not tell you whether a provider is accepting new patients, or whether a provider speaks your language. It is up to your Marketplace to require insurers to provide you with this information.
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Insurers can also offer “Catastrophic” plans. Catastrophic plans have the highest cost sharing. In 2019, Catastrophic plans will have an annual deductible of $7,900 ($15,800 in family plans). You will have to pay the entire cost of covered services (other than preventive care) until you’ve spent $7,900 out of pocket; after that your plan will pay 100 percent of covered in-network services for the rest of the year. Not everybody will be allowed to buy Catastrophic plans. They are only for adults up to age 30, and for older people who can’t find any other Marketplace policy that costs less than 8.3 percent of their income.
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Plans in the Marketplace are separated into categories — Bronze, Silver, Gold, or Platinum — based on the amount of cost sharing they require. Cost sharing refers to health plan deductibles, co-pays and co-insurance. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out of pocket limit on cost sharing. The exception is for preventive health services, which health plans must cover entirely.
In the Marketplace, Bronze plans will have the highest deductibles and other cost sharing. Silver plans will require somewhat lower cost sharing. Gold plans will have even lower cost sharing. And Platinum plans will have the lowest deductibles, co-pays and other cost sharing. In general, plans with lower cost sharing will have higher premiums, and vice versa.
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Not necessarily. All Marketplace health plans are required to cover the ten categories of essential health benefits. However, insurers in many states will have flexibility to modify coverage for some of the specific services within each category. Any modifications must be approved by the Marketplace before plans can be offered. All health plans must provide consumers with a Summary of Benefits and Coverage (SBC). This is a brief, understandable description of what a plan covers and how it works. The SBC will also be posted for each plan on the Marketplace web site. The SBC will make it easier for you to compare differences in health plan benefits and cost sharing.
Plans might differ in other ways, too. For example, the network of health providers might be different from plan to plan.
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All qualified health plans offered in the Marketplace will cover essential health benefits. Categories of essential health benefits include:
The precise details of what is covered within these categories may vary somewhat from plan to plan.
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All health plans offered through the Marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost sharing (such as deductibles and co-pays) for covered benefits, and satisfy all other consumer protections required under the Affordable Care Act.
Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost sharing required. Plans will be labeled Bronze, Silver, Gold, and Platinum to indicate the overall amount of cost sharing they require. Bronze plans will have the highest deductibles and other cost sharing, while Platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.
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It is important that you contact both the Marketplace and the health plan and let them know you no longer need coverage. In HealthCare.gov states, you can log into your Marketplace account, select the “terminate coverage” option, and enter the required information.
If you have a family policy and want to remove one person from the policy but keep coverage in effect for others, in HealthCare.gov states, log in to your Marketplace account, select the “reporting a life change” option, and enter the required information.
If you have questions about these changes, contact one of the agents here at Hummingbird. We will be happy to assist you in updating your information through Healthcare.gov.
Making these changes through your Marketplace account will create a written record that you tried to end coverage.
Do not simply stop paying the premium for your Marketplace health plan as a way to terminate coverage. Nonpayment will eventually cause your coverage to end, but in the future, if you try to enroll in coverage again with that insurer, you might be prevented from doing so until you repay the missed premium.