What you need to know about your health insurance benefits – National Consumers League

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stethoscope_heart_92.jpgIt’s no secret that choosing a health insurance plan isn’t as easy as ordering at a restaurant. Even after purchasing a plan, actually understanding what exactly you’ve purchased is yet another stressful task. Health insurance can confuse even the savviest consumers. Read on for a few tips every consumer should know when it comes to health insurance benefits.


Your health plan most likely offers essential health benefits.

All plans purchased through the Affordable Care Act (ACA) marketplace and the majority of health plans provided by employers are required to provide a core group of medical services called essential health benefits. These services include:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Pregnancy, maternity, and newborn care 
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

To find the full list of services your plan covers and how much those services cost, check your Summary of Benefits and Coverage (SBC). You can request a copy of this document through your insurance company or access it via your online account through your insurance provider’s website.

Staying in network will save you money.

Visits to health care providers or facilities within your plan’s network are generally much cheaper than visits to out-of-network providers or facilities. The type of insurance policy you have plays a role in who participates in your plan’s network and how much you will pay if you choose to visit an out-of-network provider not covered by your plan. For example, HMO (Health Maintenance Organization) plans require you to select one primary care physician who will coordinate all of your health care services. With this plan, out-of-network providers are typically not covered at all, expect for true medical emergencies.

On the other hand, PPO (Preferred Provider Organization) plans allow you to visit any provider or specialist, in-network or out-of-network, and without a referral. Though your PPO plan may cover your out-of-network visit, you will pay more out-of-pocket for those services. Regardless of the type of plan you enroll in, be mindful of the providers in your network, as it can have a huge effect on your out-of-pocket costs.

All qualified health plans have cost-sharing limits.

All qualified health plans have an out-of-pocket maximum, which is the most you have to pay personally for covered services over the course of a year. All the money you pay for your deductible, coinsurance, and copays (but not premiums) goes toward your out-of-pocket maximum. Once you reach this limit, your insurance plan pays 100 percent for all covered medical services. Understanding how all potential out-of-pocket costs work together can be a little complicated, so here’s an example:

  • Suppose you are in a serious accident and have acquired $30,000 in medical expenses. Your health insurance plan offers a $2,000 deductible, 20 percent coinsurance, and a $5,000 out-of-pocket maximum for the year.
  • You would first be responsible for paying your deductible ($2,000).
  • After paying your deductible, you are responsible for your 20 percent coinsurance on the remaining $28,000 until you reach your out-of-pocket maximum.
  • Since 20 percent of $28,000 is $5,600, you would only be responsible for paying an additional $3,000 since your out-of-pocket maximum is $5,000. Your insurance plan would then pay 100 percent for all covered medical services thereafter.   

Be on the lookout for new resources from the National Consumers League (NCL) and America’s Health Insurance Plans (AHIP) to help consumers choose and get the most out of their health insurance benefits.

Five commonly asked consumer health insurance questions – National Consumers League

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doctor_patient_crop.jpgWith the Affordable Care Act (ACA) becoming law in 2010, more Americans now have access to health care coverage than ever before. However, many consumers are still puzzled about how to select a plan, what services are covered, or why they need health insurance altogether. If health insurance talk leaves you disillusioned or just plain confused, don’t give up. Below, we answer five of the most commonly asked consumer questions about health insurance. 

Why do I need health insurance?

It is in your best interest to have some form of health insurance. Why, you ask?

  • To protect your health
    While you may seem perfectly healthy now, sudden injuries or illnesses can occur in an instant. Without health insurance, you could be faced with thousands of dollars in medical costs, which could pose a significant financial burden well into the future. With health insurance, you also have access to preventive services such as physicals, immunizations, and other screenings that can help prevent diseases and identify problems earlier when they are easier to treat.
  • It’s required by law  
    Under the ACA, individuals are required to have health insurance (unless you qualify for an exemption). If you choose not to enroll, you will have to pay a tax penalty. 

How do I know what type of insurance plan is right for me and my family?

When shopping for a health insurance plan, here are some things to take into consideration:

  • Premiums: Each health insurance plan has a monthly premium that you must pay to maintain your coverage.  
  • Coverage/access to providers: Every plan has a different set of services, prescription drugs, and doctors that it agrees to cover. Every plan also uses a specific network of hospitals and health care providers to facilitate your care. Before choosing a plan, check that the services and prescription drugs you need are covered, and ensure that your current providers are within your plan’s network to avoid incurring additional costs down the line. 
  • Out-of-pocket costs: Out-of-pocket costs are health care expenses  you must pay yourself and that are not reimbursed by your insurance plan.

 Copayment, deductibles, coinsurance … What’s the difference?

  • A copayment or “copay” is a fixed amount ($10, for example) that you pay each time you visit a health care provider or fill a prescription.
  • A deductible is the amount you are responsible for paying for covered medical services before your health insurance plan starts to pay for covered medical expenses.
  • Coinsurance is usually a percentage of a total bill that you are responsible for paying after you’ve paid your deductible (for example, you pay 20 percent and your plan pays 80 percent). 

What is a health savings account, and what can I use those funds for?                                                                         

Health savings accounts (HSA) allow you to deposit pre-tax funds to pay for qualified medical expenses. They are typically combined with qualifying high-deductible health plans (HDHP). While HSA funds cannot be used to pay for monthly premiums, HSA-eligible HDHPs are attractive to many consumers because the premiums are generally lower. HSA funds can be used as needed to pay for prescription drug costs and fees such as copays, deductibles, and coinsurance. Learn more about health savings accounts here.

If my insurance company denies coverage for a service, is there anything I can do? 

If your insurance company does not authorize payment for a medical service, you have the right to appeal that decision. Before sending an appeal, carefully review your health coverage and the correspondence from your insurance company. Have copies of your medical records, letters from your providers, and any other pertinent information that supports your appeal. If your plan still denies payment of your claim after your initial appeal, you may opt for an external review conducted by an independent third party.

To answer questions like these, the National Consumers League (NCL) and America’s Health Insurance Plans (AHIP) are teaming up to provide consumers with even more helpful information about how to choose and use health insurance benefits.

 

 

King v. Burwell ruling will keep consumers insured (and healthy!)

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Health_Care_Law.jpgThe King v. Burwell ruling in favor of the Affordable Care Act (ACA) has allowed for approximately eight million consumers to keep their insurance coverage. In the King case, petitioners challenged the clause of the Affordable Care Act that stated subsidies are available to people who use an exchange “established by the State” to purchase insurance. 

Consumers living in the 34 states without state marketplaces are able to benefit from the subsidies because the Internal Revenue Service allowed people to receive assistance if they purchased a plan on the federally-run marketplace. The plaintiffs argued that subsidies by law are only given to people living in states with their own health insurance marketplaces. The ruling allows consumers in states where the marketplace is run by the federal government to keep their subsidy and insurance.

The National Consumers League (NCL) applauds the Supreme Court for upholding the ACA subsidies for consumers using the federal marketplace. The Supreme Court decision helps prevent a rise in premiums for all consumers using the health care exchange. The subsidies are a key provision of the law and they are an important part of keeping consumers insured and healthy. This decision provides hope that the ACA will face fewer political and legal obstacles in the future and can continue to provide health insurance to consumers. Despite the naysayers, the numbers speak volumes. Since the ACA’s enactment, more than 16 million Americans have been able to afford quality health insurance they did not have before.

If you do not already have health insurance, you can enroll in person, over the phone, by mail, online at Healthcare.gov, or on your state exchange’s site during the open enrollment period.