If You Enrolled in Health Insurance Through the Exchange, Will You Really Have Coverage on January 1?

You may need to do more than cross your fingers to be sure your health insurance starts on January 1. We recommend checking with your carrier if you have not yet received proof of coverage.

This is a question on the minds of many.  With the recent tales of “834 errors*” will insurance carriers really have an accurate record of who is covered under plans sold on the exchange?

* 834 is the data transmission form sent from healthcare.gov to the carriers containing a policyholder’s information.  The 834’s have been plagued with missing, garbled, or duplicate data, casting doubt on whether carriers will receive correct and complete information.

What will happen when someone expecting to be covered on January 1 goes to the doctor, pharmacy, clinic, hospital, etc. after that date only to learn the insurance company has no record of his or her policy?

Who will pick up the pieces?  Should it be the insurance company?  The doctor, pharmacy, etc.?  The person?  The government?

What will happen?

Impact on Insurance Carriers

If you have been following things closely like we have over the past several months, you may have noticed that the insurance carriers have been asked to make last minute accommodations for some of the hiccups experienced with the roll out of the Affordable Care Act (ACA).

For example, when President Obama announced that people could keep their canceled policies after all, carriers were sent scrambling to figure out how and if they could make that happen.

Likewise, extending the January 1 enrollment date from December 15 to December 23 is helpful for the American public, but leaves the carriers somewhat short on time.  Will 9 days really be enough time to get all applications processed?

Can the insurance carriers be asked to pick up the pieces for not receiving the correct data?

Impact on Medical Providers — Doctors, Pharmacies, Hospitals

Let’s think about the providers.  Their goal is to provide medical care.

But the fact is they are also running businesses that must earn income in order to survive.  Can we expect them to provide care to an uninsured individual without being paid?  Even though the patient believed he or she was covered?

Will it only be a matter of time before doctors refuse to accept exchange insurance plans?

What Can Be Done?

These are some tough questions.  And we certainly do not have the answers.

But we can unequivocally dispense this advice:

If you have purchased new health insurance for 2014 and you have no policy documentation or proof of coverage, contact your carrier to verify that you are covered.  Do it now!

We are also watching closely to see how insurance companies react to last week’s announcement by the Department of Health and Human Services (HHS) regarding enrollments in January 1 coverage.

We continue to monitor things and be available to assist our clients.  Do not hesitate to contact us if we can be of service.

Please be patient as we manage a high volume of calls and emails.

In-network vs. Out-of-network Care

What is a network?

A network (also called provider network or preferred providers) is a group of medical providers (hospitals, doctors, specialists, pharmacies, etc.) that have contracted with an insurance company to provide medical care at an agreed-upon rate.

What is in-network vs. out-of-network care?

In-network care is medical care obtained from a provider within your plan’s network.

Out-of-network care is medical care obtained from providers outside of your plan’s network.

But, what does it all really mean?

What happens if I get out-of-network medical care?

It depends on the specifics of your plan.   While health insurance plans are not required to cover any out-of-network care, many do, at least to some extent.

Here are some things that may happen if you do receive care from out-of-network providers:

• Out-of-network care may not be covered at all, meaning you will be responsible for 100% of the cost.
• You may pay more for out-of-network care because it is covered at a lower rate than in-network care.  For example, you may pay 20% of in-network charges, vs. 40% for out-of-network charges.
• There may be a separate deductible for out-of-network care.
• The out-of-network deductible may also be higher than the in-network deductible.
• Out-of-network care may not be counted toward your annual maximum out-of-pocket limit.
• Out-of-network providers are not required to accept a contracted rate, so you may be balance-billed for some expenses over and above any covered amount.

What happens if I had no choice but to get out-of-network care?

There may be some circumstances which require out-of-network care.  For example:

• You wanted to visit a particular professional or facility for a specific covered treatment or service that was not available in your network.
• You inadvertently got out-of-network care while hospitalized in an in-network facility because one of the physicians working in the hospital (e.g. anesthesiologist, radiologist, etc.) did not participate in your plan’s network.
• You received emergency care at an out-of-network facility.

If one of these situations occurs, you can appeal the decision of your insurance company.  This is where having the assistance of a broker can really come in handy.

This kind of thing really does happen.  Click here to read a real-life situation encountered by one of our clients.

How can I protect myself from expensive, out-of-network care?

The very first line of defense is knowledge!  When purchasing coverage, make sure you know exactly what doctors, pharmacies, hospitals, and other medical facilities are part of the network for any plan you are considering.  And, make sure you understand each plan’s rules regarding use of out-of-network providers.

Once you are covered, when seeking care, always ask if a provider is part of your plan’s network — before obtaining care!

Virginia Medical Plans helps our clients understand and select the best health insurance for their needs.  Give us a call or email!