Navigator Guide FAQs of The Week: How to Use Your Coverage

Open Enrollment has ended in most states, and many consumers have signed up for a health insurance plan offered on the marketplace. In this installation, the CHIR team has compiled a number of frequently asked questions (FAQs) from our Navigator Resource Guide to help inform enrolled consumers on how best to use their coverage.

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; some plans today do cover out-of-network providers, 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 out-of-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. (45 C.F.R. § 156.130; 45 C.F.R. § 147.136).

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.

Under federal rules, insurers must provide coverage for preventive health services that the United States Preventive Services Task Force (USPSTF) recommends at an A or B rating without any cost-sharing requirements such as a copayment, coinsurance, or deductible. This means that insurers must provide coverage for preventive health services currently recommended by the USPSTF and federal guidance. You can find a list of USPSTF recommended preventive services here.

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 – 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.

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.

Note that not all plans must comply with the ACA’s preventive services requirement. See the alternative coverage section to learn more. (45 CFR § 147.130(a)(2)).

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 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. (45 C.F.R. § 147.136).

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 non-grandfathered 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.

During the COVID-19 pandemic, several states have required coverage of off-formulary drugs in certain circumstances. Contact your state insurance department to see if this option might be available to you during the pandemic.

(45 C.F.R. § 156.122; CMS, Affordable Care Act Implementation FAQs – Set 18).

Look out for more weekly FAQs from our new and improved Navigator Guide, or browse hundreds of questions and answers here.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.