Make the Most of Your ACA Insurance Plan

Now that the initial enrollment period has ended for health insurance coverage under the Affordable Care Act (ACA, or “Obamacare”), many people have insurance who didn’t have it before. And for some people, the terms of their plans are different from what they might be used to. With the help of KaiserHealthNews.org (KHN) and USA Today, here’s how to make the most of your new plan, and how to avoid incurring unexpected costs.

As the news site explains, successfully enrolling in a government exchange plan is only the first step – now you have to understand it. Like anyone else covered by an individual or employer-provided plan that conforms with the ACA, the several million people (figures were unconfirmed at this writing) who have enrolled so far in state of federal exchange plans are all guaranteed certain preventive services with no out-of-pocket costs, such as routine immunizations and pap tests. There’s also a cap on out-of-pocket medical expenses, and no one can be denied coverage because of a pre-existing condition.

But to ensure you get the full benefit of ACA provisions, you must know the guidelines, and follow the rules. They are:

  • Carry your membership card everywhere.

    Make copies. You don’t want a hassle if you have an unexpected doctor or hospital visit.

  • Understand your plan’s doctor and hospital network.

    Insurance companies negotiate participation and payment rates with a network of providers to control costs. Most exchange plan networks are smaller than what you might be used to; for an underwriter, the smaller the network, the more control it has over costs.

    Although it can be difficult, you should be able to consult a plan’s directory of providers either with the insurer online or with documents you receive when you enroll. You can find out if specific physicians are part of your network, or call their offices to ask. You should know the hospitals and urgent care facilities to ensure you stay within the network whenever possible.

  • Stay in the network!

    You can’t be charged more than the out-of-pocket limit if you use only in-network providers. Whether you’re in an HMO that pays almost no out-of-network benefits or a PPO that covers some, the pocketbook protections don’t apply if you see a doctor or go to a hospital outside of your network.

  • Try to stay in-network even for emergency care.

    Under the ACA, insurance plans do have to pay for non-network emergency visits – for example, if you’re in a car crash far from home.

    But non-network hospitals often “balance-bill” the difference between what your plan pays and what they charge, which is often much more.

  • Avoid all emergency rooms unless it’s really an emergency.

    Traditional health plans came with a modest copayment for an emergency visit – maybe $150.
    But many policies sold on the exchange, even those in the more expensive “gold” category, not only have ER copays of several hundred dollars but also subject ER charges to the overall deductible. (Copays are flat fees for specific services. Deductibles are what you pay out of pocket before the insurance kicks in.)

    So you could be billed for the full cost of an emergency visit, up to the out-of-pocket limit.
    “Broken leg?” asks KHN. “Head to the hospital. Sprained ankle? Maybe wait until the urgent care center or doctor’s office opens.”

  • Pay monthly premiums on time and accurately.

    Officially, open enrollment for 2014 coverage ended March 31 (deadlines were stretched in some cases). Open enrollment for 2015 begins Nov. 15. If you fail to pay fully and promptly you could be dropped from the plan and not allowed to re-up until the next open enrollment season. That leaves you exposed to possibly high medical costs, and possibly vulnerable to a penalty for noncoverage.

    Underpaying the premium by a small amount gives an insurance company grounds to drop your coverage. There’s a brief grace period if you get behind, but don’t push it; coverage will be terminated for nonpayment.

  • Register online with your new insurance company.

    Insurance sites track claims and enable you to shop around for the best deals on nonemergency treatment. For example, you can compare the cost of an X-ray among all of the network image providers.

  • Save paperwork. Make sure you really owe what doctors and hospitals bill you for.

    If you suspect a bill is erroneous or too high, you need the documentation to question, challenge or file it with a state oversight agency.

  • If you don’t get satisfaction from providers or insurers, try regulators.

    Check the insurer’s explanation of benefits (EOB) detailing your claims. There should be contact information for a state consumer assistance program. In addition, link here for resources provided by the Centers for Medicare and Medicaid Services (CMS) that offer state-by-state information.

  • Read your plan’s summary of benefits and coverage.

    It tells you how to file a claim, what you must pay to see a primary care doctor, what charges are imposed before or after the deductible is reached, how much it costs to go to the ER, etc.

    It’s not an exciting read, but it’s critical if you care about your health and your health-care expenditures.

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
Washingtonian Top Lawyer 2011
Avvo Rating 10.0 Superb Top Attorney Best Lawyers Firm
Contact Information