9 Simple Facts about Health Insurance

Fact #1

Open Enrollment for 2015 individual health insurance plans begins November 15, 2014.

Fact #2:

You may apply for coverage outside the dates of Open Enrollment if you have a qualifying event.

Fact #3:

All individual and small group health insurance plans effective on or after January 1, 2014 must include coverage for 10 essential health benefits — things like preventive care, well visits to the doctor, hospitalization, etc.  Click here for the full list.

Fact #4:

Health insurance plans, even those purchased through the federal or state exchanges (marketplace plans), are run by private health insurance carriers.

Fact #5:

If you need help paying for your coverage, you may be eligible for a premium subsidy, depending on your income.  To collect a subsidy you must purchase your plan through your state’s exchange.  Virginia residents use the federal health insurance exchange, healthcare.gov.  Maryland and DC have their own exchanges.

Fact #6:

Starting on January 1, 2014, you cannot be denied health insurance coverage because of a pre-existing medical condition.  This is known as guaranteed issue.

Fact #7:

Starting on January 1, 2014, you cannot be charged a higher premium because of your gender; men and women pay the same premiums.

Fact #8:

If you purchased a marketplace plan and are collecting a subsidy for your coverage, you must report any changes in income or family status that might have an impact on your eligibility for the subsidy.  Click here to learn more.

Fact #9:

Although your insurance carrier will offer automatic re-enrollment in your current plan (or one similar to it) when your coverage expires, you should carefully review your options before selecting a new plan.  You can compare your options — including premiums, deductibles, out-of-pocket costs, etc.–  using our convenient Instant Quote feature:

Virginia Medical Plans is a one-stop shop for your health insurance!

Call us at 1-800-867-0800 or email us at jkatz@vamedicalplans.com for assistance in finding the right coverage for you.

Preventive vs. Diagnostic Medical Services Under the Affordable Care Act

The Affordable Care Act (ACA) mandates that all qualified health insurance plans (except grandfathered plans purchased prior to March 23, 2010 and still in place) include coverage for ten essential health benefits.  That does not mean these medical services are necessarily free, merely that your health insurance will cover some or all of the cost.

But certain preventive services are free.  This means your health insurance must cover 100% of the service without charging you a co-payment or co-insurance, even if you have not yet met your deductible.

NOTE: you must use an in-network provider to receive free preventive care.

Preventive Services vs. Diagnostic Services

Many people are surprised to learn a service they believed to be preventive — and therefore free — was not considered preventive by the insurance company — and therefore resulted in a medical claim.

It is important to understand the difference between a preventive service and a diagnostic service.

Preventive services are things that prevent health problems.  Preventive care happens before you feel sick.  Examples are immunizations, lab tests, physical exams, certain medications.

Diagnostic services are things that help your doctor understand the symptoms you’re having and diagnose an illness. Diagnostic care happens when you feel sick or have a known health issue.

The tricky part is sometimes the same service may be preventive — and free — under certain circumstances, yet diagnostic — and not free — under others.

How Do I Know if the Care I Receive is Preventive or Diagnostic?

Whether a service is preventive or diagnostic depends on the reason for having it.

In general, a medical service is considered diagnostic if it is done for the purpose of monitoring, diagnosing, or treating a known health issue or symptom.  For example:

If you have a known, already-diagnosed chronic disease like diabetes, and your doctor monitors your condition with certain tests, these tests are considered diagnostic.

If a preventive screening test reveals a health problem and then your doctor orders more tests to further diagnose the exact issue, these tests are considered diagnostic.

If you are having symptoms, like abdominal pain, and your doctor orders tests to figure out the cause, these tests are diagnostic.

A service is considered preventive if it is done for screening purposes, and not based on any symptoms.  Certain preventive services, when done on a recommended schedule (e.g., at a certain age or frequency), are covered at 100%.

The Same Service can be Preventive or Diagnostic, Depending on the Reason

Here are a few examples of services that can be either preventive or diagnostic, depending on the reason for the service:

• Mammogram – preventive if done as a screening based on your age or family history; diagnostic if you have symptoms like pain or have detected a lump.
• Cholesterol testing – preventive if done as a screening based on your age or family history; diagnostic if you were already diagnosed with high cholesterol and your doctor is monitoring your numbers.
• Colonoscopy – preventive if done as a screening based on your age or family history; diagnostic if you have symptoms like bleeding or irregularity.
• Colon Polyp Removal – the removal itself is preventive if done as part of a screening colonoscopy; if sent to the lab for testing, this is diagnostic.

Understand Your Policy

It is best to fully understand the provisions of your health insurance policy when seeking medical care.  You can consult your plan’s documentation for specifics on your coverage.  If we helped you enroll in coverage, you can also give us a call and we’ll be glad to help!