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

Open Enrollment has ended in the majority of states, and almost 8.5 million people signed up for coverage through As consumers begin to use their 2019 plans, a host of questions about covered services, cost sharing, provider networks and more are sure to crop up. Luckily, CHIR has answers to frequently asked post-enrollment questions in our recently updated Navigator Resource Guide. Here are a few common queries:

I have a $2,000 deductible but I don’t understand how it works. Can I not get any care covered until I meet that amount?

A deductible is the amount you have to pay for services out-of-pocket before your health insurance kicks in and starts paying for covered services. Under the Affordable Care Act, preventive services must be provided without cost-sharing requirements like meeting a deductible, so you can still get preventive health care that is recommended for you.

Also, most plans must provide you with a Summary of Benefits and Coverage, which you can check to see if your plan covers any services before the deductible, such as a limited number of primary care visits or prescription drugs.

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.

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 qualified for the cost-sharing reduction when I signed up for coverage in the marketplace. I’m getting more hours at work and might not qualify anymore. Will I have to change plans now with a new deductible and out-of-pocket cap?

No one is forced to change plans due to a change in eligibility for Affordable Care Act subsidies. However, if you are enrolled in a marketplace plan, your income changed, and you now earn more than 250 percent of the federal poverty level (which is the income limit to qualify for cost-sharing reductions), you are entitled to a special enrollment period, but you can only enroll into a plan within the same metal level as your current marketplace plan. If your income no longer qualifies you for cost-sharing reductions, the insurer is required to change your plan to the correct standard silver plan or plan variation once your insurer is notified by the marketplace about such a change in eligibility. Because you’ll continue to be enrolled in a silver plan (but with different cost-sharing, appropriate to your income), then out-of-pocket costs already paid during that year must be counted against the out-of-pocket costs required under the new version of the plan.

I have a lot of unexpected bills because of a natural disaster in my area, and can’t afford to pay my marketplace premiums for the rest of the year. What are the consequences of not paying?

If you decide you can’t afford to maintain your coverage this year, you should contact the Marketplace Call Center ( at 1-800-318-2596 (TTY: 1-855-889-4325) as soon as possible to terminate your coverage and if applicable, stop receipt of any premium tax credits. You should also contact your health insurance company to ensure your health plan is terminated. Make sure to document the dates of your contacts with the marketplace and the insurer.

Recent federal guidance allows insurers to extend the grace period for consumers who are receiving premium tax credits, if the insurers are requested or directed to do so by state authorities. If, due to a natural disaster in your area, you were uninsured for an extended period of time in 2018, you could qualify for an exemption from the ACA’s individual mandate penalty. For more information on how to request such an exemption, see this FAQ.

Note that in future open enrollment periods, insurers may condition your re-enrollment in their plan on payment of any outstanding premiums. However, insurers must provide notice of the new policy before they can apply it to you for failing to pay premiums. Also, the policy only applies to the insurer to whom you owe outstanding premiums. Other insurers offering plans in your area cannot deny you coverage for failing to pay premiums to another insurer.

For more answers and resources, visit our new and improved Navigator Resource Guide.

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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.