Help! I Don’t Understand My Marketplace Insurance

A TMA “Hey, Doc” Production

Confusion reins in the marketplace

Half a year after policies purchased via the Affordable Care Act (ACA) online marketplace exchanges first took effect, research studies and media reports show that many of these newly insured Americans don’t understand their insurance or how to use it.

“Hey Doc” is pleased to reissue some of our articles and videos to help answer such critical questions as:

How Do I Know What Coverage I Have?

What Are Deductibles, Co-Insurance, and Co-Payments?

What Is Covered by This Insurance?

What Is My Marketplace Insurance ID Card For? What Do I Do If I Didn’t Get One?

Why Is It Important to Pay My Marketplace Insurance Premium on Time?

What Will It Cost Me to Use This Insurance?

What Are the Limits on Out-of-Pocket Costs?

How do I find out if my doctor is on my insurance plan’s list?

What should I do if I thought my doctor was included, but really isn't?

I can't find the specialist I need on my insurance plan’s list of doctors. What should I do?

How do I know what coverage I have and if I can use it?

There are a few things you can do before you visit the doctor’s office to prepare so you know what your benefits and costs are.

First off, you want to make sure you’ve paid your premiums on time so that your insurance takes effect. Just signing up is not enough.

You can call your insurance company to get details on the plan you bought. Healthcare.gov representatives should be able to provide you a contact phone number. Talk to a representative by calling (800) 318-2596. Or you can use a list of marketplace plan websites that TMA compiled to find the phone number you need.

How do I know what coverage I have and if I can use it?

If you’re just now enrolling in a health plan through the marketplace, either online or by phone, make sure you write down the member ID number you receive. You’ll need that number to check on your benefits when you call your insurance company. Or if you already received a member ID card, you can use that information when you call.

Your insurance company also should send you a welcome packet after you enroll. That should explain what type of plan you bought and what your benefits and costs are.

Where can I go to check my coverage?

Marketplace plan websites and phone numbers (page 1): 

Ambetter Superiorwww.superiorhealthplan.com/for-members/(877) 687-1196 

Blue Cross and Blue Shield of Texaswww.bcbstx.com/health-care-reform/health-insurance-exchange(866) 716-5427 

Aetnawww.aetna.com/about-aetna-insurance/contact-us/forms/about/contact_us.html?WT.svl=ContactUs(800) 872-3862 

Humanahttps://www.humana.com/individual-and-family-support/contact-us (800) 833-6917 

CIGNAwww.cigna.com/aboutcigna/contact-us/ (866) 438-2446(800) 244-6224 (If you lost your ID card) 

Community Firstwww.cfhp.com/ContactUs/(800) 434-2347

Where can I go to check my coverage?

Marketplace plan websites and phone numbers (Page 2):

Community Health Choicehttps://www.chchealth.org/About%20CHC/Contact_Us.aspx(888) 760-2600 

First Carewww.firstcare.com/contact-us(800) 884-4901 (HMO)(800) 240-3270 (PPO) 

Molinawww.molinahealthcare.com/members/tx/en-US/hp/marketplace/pages/enroll.aspx(855) 540-1985 

Scott & White Health Planhttps://swhp.org/members(800) 321-7947 

Sendero Health Planwww.senderohealth.com/en/members/member-resources(855) 526-7388

What are deductibles, co-insurance, and co-payments?

Deductibles, co-insurance, and co-payments basically describe the costs you share with the insurance company and pay to physicians and other providers for your health care.

Let’s start with the deductible, because that’s the amount you typically have to pay first before your insurance starts to cover much of your health care costs. Say you have a $1,000 deductible for the year. That means you’re responsible for paying the first $1,000 of your medical expenses before the insurance company helps pick up the rest. You might meet that deductible in one hospital stay, or you could meet it throughout the year in multiple doctor visits. Because your insurance policy covers one year at a time, you would meet that deductible once a year, and it resets when you renew your insurance. And depending on your plan, once you’ve met your deductible, your insurance will start to cover a greater portion of your medical expenses.

What are deductibles, co-insurance, and co-payments?

Which brings us to the co-insurance, which is different. Instead of a fixed amount, like the deductible, the co-insurance is the percentage of a particular medical cost that you are responsible for. Let’s say it costs $100 for an x-ray and your co-insurance is 20 percent. You would pay $20 of that cost, and your insurance would pay the rest, $80. Depending on your plan, that $20 could go towards your deductible, or sometimes the co-insurance won’t kick in until after you’ve met your entire deductible. And the co-insurance amount can vary depending on whether you receive medical services in or outside of your health plan’s network.

Lastly, each time you visit the doctor, you’ll typically pay what’s called a co-payment or “co-pay.” It’s usually a small fixed fee, like $25, that you pay up front at each visit, not something you split with your insurance plan. But it can also vary depending on the medical service.

But marketplace plans must cover certain preventive services, like screenings and immunizations, without making you meet your deductible, or pay co-insurance or co-payments, That’s if you get those services in-network.

And keep in mind that the health care law puts a limit on your out-of-pocket medical expenses each year. Once you reach that limit, your insurance usually covers 100 percent of your medical expenses.

What is covered by this insurance?

All plans in the marketplace have to offer what’s called “essential health benefits.” This is a basic package covering 10 different categories:

Doctor visits;

Hospital visits;

Prescription drugs;

Lab tests;

Emergency room visits;

Care when you are pregnant and when you have your baby;

Care for children;

Preventive services that help you stay healthy, like shots and screenings;

Mental health care like counseling; and

Treatments that help you recover from injuries.

Some plans might cover more than that, but that’s the minimum. You can also find dental coverage in the marketplace, either included in a plan you buy, or separately. Marketplace plans also must cover what are called “preexisting health conditions.” This means even if you are already sick or pregnant

What is my marketplace insurance ID card for? What if I didn’t get one?

As with most health insurance, your marketplace health plan will give you an insurance card, or member ID card, once your insurance application is approved and you’ve paid your first premium. Typically the card shows your name (or the head of your family’s name if it’s a family plan); a member identification number; a group number; a phone number for your health plan; and the type of plan you purchased. Depending on your plan, the card might include a few other pieces of information, like your primary care doctor’s name. When you go to get health care, this information helps your doctor, hospital, or pharmacy know what kind of insurance coverage you have, what your visit or medications will cost, and how much you pay for versus what your insurance company pays.  

With the delays in the launch of the marketplace, some insurance companies fell behind on processing enrollments, and a lot of people did not receive their cards. If that’s you, call your insurance company to check the status of your application and request a card. If you still don’t have a card by the time you need to visit the doctor or hospital, call your insurance plan ahead of time to find out your member ID and group numbers and the type of health plan you have, and bring that information to your visit. Also, most insurance companies are sending out welcome letters after you sign up that show this information.

Why is it important to pay my marketplace insurance premium on time?

Remember that when you buy your insurance, you pay a set monthly fee, called a premium, to make sure it’s there for you when you need it. But for your insurance to actually work, you have to pay that premium on time. If you don’t, you could be responsible for paying your entire health care bill out of your own pocket. Not paying your premiums on time also means you could miss out on other financial help for your medical bills.  

Signing up for an insurance plan is step one. And having a marketplace insurance ID card does not necessarily mean you have active insurance coverage unless you are paying your premiums. Once you sign up, your insurance company will tell you when your payment is due. It will usually be the same time each month, depending on when you first signed up. Most health plans also offer different ways to pay your premiums, like by check or by money order, or by mail or by automatic payments.

What will it cost me to use this insurance?

There are different types of costs you will pay to use your insurance.

Remember that when you first buy your insurance, you pay a set monthly fee to make sure it’s

there for you when you need it, called a premium. That premium depends on a few things, like

where you live, your age, how many people are in your family, the services you need, and

whether you smoke. Depending on your income, you might also qualify for a subsidy to lower

your premiums. So premiums are different for everyone. And it’s important to pay those

premiums on time, even when you are not using your insurance, so you are covered when a

medical issue does come up.

Then, when you go to use your insurance — at the doctor’s office, or hospital, or pharmacy, for

instance — you share some of the costs of your medical care with the insurance company. Those

costs are called deductibles, co-insurance, and co-payments. You might hear this referred to as

“cost-sharing” or “out-of-pocket costs” because while your insurance plan helps cover a good

portion of your medical expenses, you also pay for some of those costs out of your own pocket.

And those amounts depend on which type of plan you choose and what category it falls into:

bronze, silver, gold, platinum, or catastrophic.

What are the limits on out-of-pocket costs?

The health care law puts a limit on what you pay each year out of your own pocket for the medical expenses covered by your insurance, called “out-of-pocket limits.” For 2014, the out-of-pocket limits are $6,350 for an individual plan, and $12,700 for a family plan for the year. That’s the most you would pay for the year, and after you reach that limit, your health plan pays for 100 percent of the services it covers. What counts toward your out-of-pocket limits? It doesn’t include your premiums. But depending on your health plan, it can include costs like deductibles, co-insurance, co-pays, and sometimes care that’s out of your plan’s network.

How do I find out if my doctor is on my insurance plan’s list?

If you’re not sure if your doctor participates in your insurance plan, there are few ways to find out.

Marketplace rules require plans to publish an online directory of participating doctors on Healthcare.gov. It’s important to check those lists before you buy insurance to find out if your doctor is in the plan you want. You also can call your insurance company to check if your doctor is in the plan. Or, the information might be included in the welcome packet you got when you first enrolled.

You might have heard about some confusion over whether the insurance plan lists online are up to date. So if you aren’t sure, call your doctor directly to find out if he or she is participating in the plan you choose.

What should I do if I thought my doctor was included, but really isn't?

If your current doctor is not in your insurance plan, you have a few options:  

If you decide to keep your doctor and he or she is not in your plan, you may have to pay the full cost of your medical bills

You can choose another doctor within your plan.

Or, even if your coverage already started and you paid your premium, the federal government recently said that you might be able to pick another plan with your doctor, as long as the plan is with the same insurance company and in the same “metal” level as the one you signed up for in the first place. 

And if you do decide to switch, be sure to ask your doctor first which plans he or she takes.

I can't find the specialist I need on my insurance plan’s list of doctors. What should I do?

Remember that insurance plans in the marketplace must sign up enough doctors, hospitals, pharmacies, and other providers to make sure patients can get medical care. When you don’t have a choice and your plan’s network doesn’t include the type of specialist you need, you can see a doctor that’s not on your plan. But your health plan can’t charge you more than you would pay if that doctor actually was on your current insurance plan.

The same thing applies if you have to get emergency care out of network. If it’s not an emergency, be sure to call your insurance company ahead of time to arrange to see an out-of-network specialist.

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