So, You’ve Got Health Insurance. What Now? Frequently Asked Questions on Post-Enrollment Issues

Open Enrollment ended in most states on December 15, 2019. In the remaining states, Open Enrollment ends this month. For the majority of Americans who enrolled in health insurance before the December 15 deadline and paid their first premium, insurance should now be kicking in. We’ve collected a series of frequently asked questions (FAQs) from our Navigator Resource Guide on post-enrollment issues to help consumers navigate their first few months of having a new insurance plan.

Are annual physicals for adults and children available without cost-sharing as part of the preventive service requirements?

Yes, routine annual physicals are covered as part of the preventive service requirements of the ACA. This means that insurers must provide coverage for preventive health services currently recommended by the United States Preventive Services Task Force (USPSTF) and federal guidance.

Some plans will also cover some limited services prior to meeting a deductible such as primary care visits, some urgent care, or a limited number of prescription drug refills. Check your Summary of Benefits and Coverage for information on what services are covered before the deductible is met.

Under federal rules, insurers must provide coverage for preventive health services that the USPSTF recommends at an A or B rating without any cost-sharing requirements such as a copayment, coinsurance, or deductible. For example, if you are man 35 and older and go to the doctor’s office for an annual physical, and are screened for cholesterol abnormalities as part of your annual physical, the insurance company cannot impose cost-sharing for either the physical or the cholesterol abnormalities screening. Note, however, that the law covers preventive care and if there is a medical reason for a service, then you may have some cost-sharing requirements. Take the previous example with the man 35 and older, if he goes into his annual physical to discuss reoccurring stomach pain and the doctor bills separately for an office visit for any services to address the stomach pain, these services will likely not be considered preventive care. You can find a list of USPSTF recommended preventive services here. Note that not all plans must comply with the ACA’s preventive services requirement. See FAQs on alternative coverage to learn more.

I went for a preventive screening colonoscopy and received a bill for the anesthesia used during my procedure as well as for the pathology exam to examine the polyp that the doctor found. Is this allowed?

No, not under an ACA plan. Anesthesia must be covered without cost-sharing if your doctor determines that anesthesia services are medically appropriate for you. The pathology exam for the polyp biopsy must also be covered without cost-sharing because this is an integral part of the colonoscopy preventive screening to determine whether a polyp is malignant. Additionally, if your doctor determines that you need a pre-colonoscopy consultation to determine whether or not you are healthy enough to undergo the preventive colonoscopy, the consultation must be covered as well without cost-sharing.

I was denied coverage for a service my doctor said I need. How can I appeal the decision?

If your plan complies with the Affordable Care Act and it denied you coverage for a service your doctor said you need, you can appeal the decision and ask the plan to reconsider their denial. This is known as an internal appeal. If the plan still denies you coverage for the service and it is not a grandfathered plan, you can take your appeal to an independent third party to review the plan’s decision. This is known as an external review.

You will have 6 months from the time you received notice that your claim was denied to file an internal appeal. The Explanation of Benefits you get from your plan must provide you with information on how to file an internal appeal and request an external review. Your state may have a program specifically to help with appeals. Ask your Department of Insurance if there is one in your state.

For more information about the appeals process, including how quickly you can expect a decision from your plan when you file an internal appeal, click here.

What happens if I end up needing care from a doctor who isn’t in my plan’s network?

Plans are not required to cover any care received from a non-network provider, though some plans today do, although often with much higher co-payments or coinsurance than for in-network services (e.g., 80 percent of in-network costs might be reimbursed but only 60 percent 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. Contact your state insurance department to see if there are programs to help you with your appeal and more information on how to appeal.

I was in the hospital when my coverage changed from my old plan to my new, marketplace plan. My provider during that episode of treatment is no longer in my plan’s network and I’m worried I’ll face higher cost-sharing as a result. Is this allowed?

Yes, you may have to pay more out of pocket for services from providers who are out-of-network. However, depending on the state that you are in, your new health plan may be required or encouraged to allow you to see your provider at in-network cost-sharing rates through your course of treatment. Check with your health plan or state department of insurance to see if this protection applies to you.

My doctor says I need a prescription drug, but it’s not in my health plan’s formulary. I didn’t realize that when I enrolled in the plan. Shouldn’t my plan be required to cover a drug that my doctor says I need?

All new plans sold to individuals and small employers must have procedures in place to allow enrollees to request and gain access to clinically appropriate drugs even if they are not on the formulary. However, that process may take time, and you may need immediate access to drugs your doctor prescribed. Therefore, marketplace insurers are encouraged to temporarily cover non-formulary drugs (including drugs that are on the plan’s formulary but require prior authorization or step therapy) as if they were on the formulary. This policy would apply for a limited time – for example, during the first 30 days of coverage – and is not required of insurers. But hopefully it will give you enough time to request an exception to the formulary so you can get your prescription covered. Note, that non-ACA plans do not have to meet the exceptions requirement.

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