Health insurance coverage – now what?

February 26, 2014

By RAY HURD
MEDICARE
The Affordable Care Act created the Health Insurance Marketplaces, which means thousands of Connecticut residents now have the ability to enroll in health insurance coverage, many for the first time. Navigating the health insurance industry can feel overwhelming, but it is important to remember that your health insurance coverage offers access to benefits that can help keep you healthy.
Once you’re enrolled in a health plan and your coverage has started, you can use it to help cover medical costs for services like going to the doctor, filling a prescription at the pharmacy and getting emergency care.
One of the most important steps you can take to improve your health is to seek appropriate care through a primary care physician. Most health plans give you the best deal on services when you see a doctor who has a contract with your health plan. While you may be able to see doctors who don’t contract with your health plan, visiting an “in-network” provider usually means you will have lower out-of-pocket costs. To find a doctor “in-network” you can visit your health plan’s website and check their provider directory. A provider directory is a list of the doctors, hospitals and other health care providers that your health plan contracts with to provide care. In addition to checking online you can call your insurer to ask about specific providers or call a doctor’s office directly to see if they accept your insurance.
Health plans also will help pay the cost of certain prescription medications. You may be able to buy other medications, but medications on your health plan’s “formulary” (approved list of prescription medications) usually will be less expensive for you. To find out which prescription drugs are covered, visit your insurer’s website and review the list of covered prescriptions. You can also find this information in your Summary of Benefits and Coverage documentation. If you still have questions about covered medications, you can always call your insurer directly to find out if a particular medication is covered.
Now that you know different health plans cover different medications, it’s important to note that different health plans allow you to get your medications from different pharmacies (called “in-network” or “specialty” pharmacies). Call your insurer or visit their website to find out whether a local pharmacy is in-network under your new health plan and, if not, what pharmacies in your area are in-network. You can also learn whether you can get your prescription delivered to you in the mail, which may be a convenient option for you.
In an emergency, you should get care from the closest hospital that can help you. Your insurance company can’t charge you more for getting emergency room services at an “out-of-network” hospital.
If your health insurance company doesn’t pay for a specific healthcare provider or service, you have the right to appeal the decision and have it reviewed by an independent third party. Your insurance company must first notify you in writing within a set amount of time. Based on the type of claim you file, your health plan will need to explain why coverage was denied. They also have to let you know how you can appeal their decision.
If the timeline for the standard appeals process would seriously put your life at risk, or risk your ability to fully function, you also can file an appeal that would get you a quicker decision. If you meet the standards for an expedited external review, the final decision about your appeal must come as quickly as your medical condition requires, and no later than 72 hours after your request for external review is received.
In addition to creating the Health Insurance Marketplace, the Affordable Care Act is providing consumers with new benefits and protections. Health insurance plans can’t refuse to cover you or charge you more just because you have a pre-existing health condition. And many preventive screenings are now available to you at little or no out-of-pocket cost.
It remains imperative that consumers learn about the health insurance industry and their individual health plans. Always ask questions and carefully review your health plan’s certificate of coverage to ensure you are taking full advantage of the benefits offered.
If you have additional questions about the Health Insurance Marketplace, call 1-800-318-2596. (TTY users should call 1-855-889-4325.)
Ray Hurd is Medicare’s Regional Administrator for Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Puerto Rico, Rhode Island, Vermont and the Virgin Islands.

 

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