Navigator Guide FAQs of the Week: Post-Enrollment Issues



Open enrollment for the Affordable Care Act’s Marketplaces has ended in most states, with a record number of people selecting a Marketplace plan for 2024. Enrollees may have questions about using their 2024 coverage. Here are some answers to common post-enrollment questions from our Navigator Resource Guide.

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. (45 C.F.R. § 147.130; CMS, Affordable Care Act Implementation FAQ – Set 18).

I was denied coverage for a service my doctor said I need. How can I appeal the decision?

If you are enrolled in an ACA-compliant plan, you will have 180 days (six months) from the time you received notice that your claim was denied to file an internal appeal. The “Explanation of Benefits” (EOB) form that you get from your plan must provide you with information on how to file an internal appeal and request an external review. If your plan is fully insured, you can get help filing an appeal from your state’s department of insurance. Your state may have a program specifically to help with appeals. (HealthCare.Gov, Internal Appeals.)

En español

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. Out-of-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 unless it is a situation covered by state or federal protections against such bills, including emergency care or an out-of-network provider at an in-network facility.

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—you can appeal the insurer’s decision. If you inadvertently got out-of-network care while at an in-network hospital, for example, if the anesthesiologist or other physicians working in the hospital don’t participate in your plan network, contact your health plan or insurer. Federal protections that took effect January 1, 2022, may prevent the provider from sending you a surprise medical bill for charges not covered by your insurer and you can ask for an internal appeal and external review. 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).

En español

Thanks for tuning in to our “Navigator Guide FAQs of the Week” throughout the open enrollment season! Consumers in some states can still sign up for 2024 Marketplace coverage, and certain life events may trigger a mid-year enrollment opportunity. Check out our Navigator Resource Guide for hundreds of additional FAQs, including more answers to post-enrollment questions, as well as state-specific information and other helpful resources.

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