Translating Coverage into Care: Answers to Common Post-Enrollment Questions

Open enrollment has ended, and almost 12 million individuals signed up for coverage through the state and federal marketplaces. While enrolling in health insurance raises an abundance of questions, selecting a plan is only the beginning. Once you’re in a plan, using your benefits, accessing care, and potential confusion about the Affordable Care Act’s (ACA) individual mandate bring their own set of challenges. To help answer common post-enrollment questions, we cracked open our trusty Navigator Resource Guide.

My plan doesn’t cover maternity services, or other health care needs

While the ACA requires individual health plans to cover the ten Essential Health Benefit (EHB) categories, including maternity care, some insurance plans and products are not subject to this protection. If you purchased a policy or product that does not comply with the ACA’s consumer protections and market reforms, you may not be covered for things like mental health, maternity care, prescription drugs, and other essential services.

If you are enrolled in a grandfathered plan, or you renewed coverage in your plan before January 1, 2014 (often called a transitional or grandmothered plan), it is possible that your coverage does not have to meet the ACA’s EHB requirement, and does not cover certain health services. Your insurer must tell you if your plan is grandfathered, and if your plan is grandmothered, your insurer was supposed to inform you that your coverage does not meet all of the ACA’s protections.

You also may have purchased an insurance product that is not subject to the ACA’s EHB requirements because it is not traditional health insurance. Medical discount plans, short-term insurance, and fixed indemnity policies are some of the products that are not considered health insurance and therefore are not subject to the requirement to cover the 10 EHB categories. If you believe you purchased one of these policies – and thought you were purchasing health insurance – you should notify your state’s Department of Insurance.

My doctor says I need care, but my insurance won’t pay for it

If your plan denies you coverage for a service your doctor said you need, you can appeal the decision and ask your insurer to reconsider their denial (an “internal appeal”). You have six months from the time that you received notice that your claim was denied to file an internal appeal. If the plan still denies you coverage for the service after an internal appeal, and it is not a grandfathered plan, you can take your appeal to an independent third party to review the plan’s decision (an “external review”). 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.

I need care from a doctor who isn’t in my plan’s network

Health plans are not required to cover any care received from a non-network provider. Some plans do, but 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 costs for 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 are also not contracted to limit their charges to an amount the insurer says is reasonable, so you might also be responsible for the difference between your plan’s provider reimbursement and what the provider chooses to charge, or “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 that deliver the care you needed – 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’s network, you can appeal the insurer’s decision (see appeals question above).

I missed Open Enrollment. Can I still sign up for coverage?

Once the open enrollment period is over, individuals and families cannot enroll in marketplace health plans until the next open enrollment period later this year. However, if you experience certain changes in circumstances outside of the open enrollment period, such as moving to a new area, leaving a job, or having a baby, you may have a special 60-day opportunity to enroll in marketplace health plans through a special enrollment period. The marketplace will ask you to provide verifying documents prior to enrollment for certain qualifying events.

Individuals who qualify for Medicaid or CHIP can enroll in the public programs throughout the year, not just during open enrollment. American Indians and Alaska Natives can enroll in marketplace plans outside of open enrollment without needing a special enrollment opportunity.

I heard they repealed the individual mandate. Do I still need to have coverage this year?

Yes, you still need to have coverage this year to avoid paying a penalty. The ACA’s individual mandate was not repealed. The Tax Cuts and Jobs Act that was signed into law in December 2017 reduced the tax penalty for not complying with the ACA’s individual responsibility requirement to $0 beginning in 2019. That means that federal law still requires you to have minimum essential coverage for 2018, or risk paying the penalty if you do not qualify for an exemption from the coverage requirement.

The penalty does not zero out until plan year 2019, for which most people will file taxes in 2020. When you file taxes in 2018 for 2017 and in 2019 for 2018, if you did not have minimum essential coverage for the entire year, you may be liable for a tax penalty, equal to the greater of:

  • $695 for each adult and $347.50 for each child, up to $2,085 per family, or
  • 5% of family income above the tax filing threshold, capped at the national average of the lowest cost bronze plan available through the marketplace.

Some types of coverage sold outside the health insurance marketplaces do not qualify as minimum essential coverage, such as medical discount cards, short-term and fixed indemnity policies. These kinds of products are sometimes referred to as “excepted benefits,” and do not fulfill the ACA’s individual responsibility requirement, potentially exposing you to the tax penalty while it is still in effect. To find out if your plan counts as minimum essential coverage, look over you Summary of Benefits and Coverage, or contact your insurer.


Check out more answers to post-enrollment questions and other helpful information in CHIR’s Navigator Resource Guide, made possible by the Robert Wood Johnson Foundation.

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