HOW TO USE HEALTH INSURANCE

  • Once I have health insurance, what kind of things should I be using it for?

    One of the biggest benefits of having health insurance is that it can be used to help you stay healthy. Many health insurance plans under the new healthcare law include preventive services that you and your family can use without a copay, even if you haven’t met your deductible. These preventive services include everything from various disease screenings to vaccines.

    Of course, your health insurance also helps you when you’re sick, by covering medically necessary care for doctor and hospital visits, emergency care, and prescription drugs.

  • Where can I go for care?

    Where you go depends on your symptoms – are you having a medical emergency or do your symptoms call for more routine, non-emergency care? Although the list below doesn’t cover every possibility, it’s a good “rule of thumb” for understanding when to go where. When in doubt, call a healthcare professional.

    Your Doctor’s Office
    • Office hours vary
    • Usually lowest out-of-pocket cost
    • Generally the best place to go for non-emergency care

    You can use it for:

    • General health issues
    • Annual health exams
    • Vaccinations
    • Flu and colds
    • Minor aches and pains
    Specialist
    • Office hours vary
    • Focuses on a specific area of medicine
    • Depending on your health insurance plan, you may need a referral from your regular doctor
    Retail Health Clinic
    • Walk-in clinics are often located in stores and pharmacies to provide convenient, low-cost treatment for minor medical problems
    • Similar to retail store hours
    • If your plan doesn’t include the retail health clinic, you may need to pay out-of-pocket costs when you receive care

    May be good for:

    • Common illnesses, such as pink eye or strep throat
    • Minor wounds, cuts and abrasions, and skin conditions like poison ivy
    • Flu shots
    Urgent Care Provider
    • Generally open evenings, weekends, and holidays in addition to regular business hours
    • If your plan doesn’t include an urgent care provider, you may need to pay out-of-pocket costs when you receive care
    • May offer care when your regular doctor is not available or you don't need the level of care an emergency room provides

    May be good for:

    • Stomach pain
    • Minor falls and cuts
    • Urinary tract infections
    • Sprains and strains
    Emergency Room (ER)
    • 24 hours, seven days a week
    • Highest out-of-pocket costs
    • Treats serious illnesses and injuries – use the ER for life-threatening injuries or conditions that can’t be treated anywhere else

    Best choice for:

    • Major cuts and fractures
    • Serious injuries
    • Heart attack
    • Stroke
  • How do I choose a doctor who’s right for me?

    There’s no “one size fits all” answer. But a good place to start is by thinking about what you and your family need and want from your doctor. Some good questions to ask include:

    • Is the doctor in your health insurance plan’s network? (If not, you’ll pay more.)
    • If you’re seeing a specialist, is he or she board certified, demonstrating expertise in that particular specialty?
    • Is the office location convenient for you?
    • What are the doctor’s office hours? What days is the office open?
    • How long is the usual wait for an appointment?
    • Does the office communicate effectively with you? These days, some doctors let you email them questions.
    • How long has the doctor been practicing?
    • Can the doctor treat your entire family?
    • Can things like X-rays and lab tests be taken care of at the office?
    • Do you have specific language requirements?
  • Is there a dollar limit to how much I can use my health insurance?

    Starting in 2014, the new healthcare law specifically prohibits both annual and lifetime dollar limits on essential health benefits. But health insurance plans may limit what they pay for other items and services, like visits for therapy services.

  • What’s a primary care physician – and do I need one?

    For many people, their primary care physician is simply their “regular doctor” – the physician you go to for most of your care, including check-ups and vaccinations.

    But some health insurance plans – especially an HMO – may require you to choose a primary care physician to coordinate your healthcare and make referrals before you can see a specialist.

  • What’s a specialist?

    A specialist is an expert in a specific area of medicine. For example, a cardiologist (a heart doctor) is a specialist. An HMO plan typically requires you to get a referral from your primary care physician to see a specialist. In other words, if you have an HMO, you can’t just call a specialist’s office for an appointment – your primary care physician has to "refer" you.

  • How will I be billed?

    After you receive medical care, you’ll typically receive a bill and an Explanation of Benefits.

    • Bills come directly from your hospital, doctor, or other health professional. Your final bill will show the services you received, the amount your health insurance plan paid, and any payment you need to make.
    • An Explanation of Benefits comes from your health insurance company. It is not a bill. It shows what your hospital, doctor, or healthcare professional billed to your health insurance on your behalf, the amount your health insurance will pay for those services, and any amount you may owe.

    You don’t "pay" an Explanation of Benefits. You pay your hospital, doctor, or other health professional after you get a final bill.

  • How does a Health Savings Account (HSA) work?

    A health savings account, or HSA, is a special kind of savings account for out-of-pocket medical expenses. The money you save stays in your account until you spend it – you don’t forfeit unspent money at the end of the benefit year or if you change jobs. HSAs can be a smart way to save for future or unexpected expenses – things like having a baby or medical emergencies.

    HSAs can help you save money, too. You do not pay taxes on the money you put in your HSA - as long as you use the money for eligible out-of-pocket costs.

    You must be enrolled in a high-deductible health plan to open an HSA (a plan with a higher deductible than most other plans). And there is a limit to how much you can save to your HSA each benefit year. In 2014, you can contribute up to $3,300 as an individual or up to $6,550 for a family.

  • How do I make sure I’m getting my money’s worth from my health insurance?

    Beyond the security that health insurance provides you and your family, there are several things you can do to make sure you’re taking full advantage of your health insurance plan.

    • Read up on your benefits. Your health insurance may offer discounts for health and wellness products, like gym memberships or classes on fitness and good nutrition.
    • Take advantage of the “extras.” The new law builds many preventive services like screenings and vaccinations into your plan, with no out-of-pocket costs. For example, your health insurance probably covers an annual flu shot.
  • Can my health insurance drop me or cancel my coverage?

    In most cases, no. But if you deliberately put false or incomplete information on your health insurance application, your insurance company may have grounds to cancel your coverage. And if you don't pay your premiums, your insurance company has the right to cancel your coverage.

    If your health insurance company notifies you that it’s dropping you, you have at least 30 days to appeal the decision.

The Healthcare Law and You

  • What is the new healthcare law?

    The Affordable Care Act offers you and your family new rights and protections. Here’s what healthcare the law provides:

    • Access to insurance regardless of your health. Beginning in 2014, you can’t be denied or charged more for health insurance just because you have a pre-existing medical condition, like asthma, heart disease, or cancer.
    • Longer coverage for young adults. Children can stay on their parents’ health insurance until they turn 26, even if they’re married or living on their own.
    • A new place to buy health insurance. Beginning in October 2013, the Health Insurance Marketplace – also called the “exchange” – offers another place to shop if you are buying insurance for yourself or your family. (You’ll still be able to purchase health insurance directly from a health insurance company or through your employer, if you have that option.)
    • A focus on helping you stay healthy. Many preventive care services for adults and children now come with no additional out-of-pocket costs.
    • Essential health benefits must be included. Beginning in 2014, all health insurance plans sold directly to individuals must include a package of essential health benefits on medically necessary care for doctor visits, prescription drugs, tests, and emergency care.
    • No annual or lifetime dollar limits. Health insurance companies can’t set a dollar limit on the essential health benefits you are eligible to receive.
    • Rate hikes of at least 10% will be reviewed. Your health insurance company must justify any rate increase of 10% or more to a state or federal rate review program.
    • A rebate if your premium isn’t spent directly on health services. If you buy your own health insurance, your insurance company must give a rebate if it spends less than 80% of all of the premiums it collected on care and quality improvement.
    • No cancellations for honest mistakes. Your insurance company can’t drop you just because you made a minor, honest mistake on your application. (But you can still be dropped for providing false or misleading information or failing to pay your monthly premium.)

    Many of these features are already in place, and the others kick in with plans that take effect starting January 1, 2014. But if your current health insurance plan was in place on or before March 23, 2010, it may be “grandfathered” – exempt from some of the law’s requirements. Check with your health insurance company to understand your benefits.

  • If I have health insurance now, do I have to do anything?

    Most people who already have health insurance won’t be required to do anything. The new healthcare law only requires that you have health insurance starting January 1, 2014.

    Most existing health insurance plans qualify under the law. If you have health insurance through your employer, for example, you do not need to get new health insurance. Some, but not all, individual health insurance plans may also be grandfathered.

    These grandfathered plans count as health insurance under the new law, also. But grandfathered plans do not have to include all of the new healthcare law’s benefits and protections.

    You can check with your health insurance company to find out if your plan is grandfathered and how its features compare to the new law. (You can check your local Blue Plan here.)

  • If I don’t have insurance, do I have to buy it?

    Yes, in almost all cases.

    Starting in 2014, most people must have health insurance or pay a penalty (unless they qualify for an exemption). Your health insurance can come from different sources: your employer, a health insurance plan you purchase yourself, or government programs like Medicaid or Medicare.

    There are a few exceptions, including people with very low incomes, those qualifying for religious exemptions, and members of Indian tribes.

  • Can I get help if I can’t afford health insurance?

    You may be eligible for financial assistance from the government. The amount depends on your income and family size. Try our financial assistance estimator to find out if you might be eligible.

    If you receive financial assistance from the government, you may be able to purchase your health insurance through the Health Insurance Marketplace (you may hear it called the “exchange”) or directly from a health insurance company.

    When you visit your state’s exchange, you’ll find out if you qualify for financial assistance from the government. If you qualify:

    • You can buy directly on the exchange – your cost should reflect any financial assistance from the government that you may receive
    • Many states also allow you to apply your financial assistance from the government to a plan you buy directly from a health insurance company

    Some people also may be eligible for free or very low-cost coverage through Medicaid and the Children's Health Insurance Program (CHIP).

  • What happens if I don’t have health insurance?

    Starting in 2014, you’ll pay a penalty if you can afford health insurance, but choose not to buy it (some exceptions apply – see below).

    For individuals, the penalty is 1% of their income or $95, whichever is larger. The fee for children who aren’t insured is $47.50 per child. According to the US government, however, the most a family would have to pay in 2014 is $285. The penalty rises in 2015, then again in 2016.

    Not everyone will face a penalty, though. For example, you won’t have to pay a penalty if:

    • You will be without insurance for less than 3 months of the benefit year;
    • You have a very low income;
    • You qualify for religious exemptions; or
    • You are a member of an Indian tribe

  • What is the Health Insurance Marketplace?

    Under the new healthcare law, each state will offer a Health Insurance Marketplace (you may hear it called an “exchange”). The marketplace, or exchange, is another way to shop for health insurance, with a website where you can compare different options. Tools on the marketplace allow you to compare plans from multiple health insurance companies by price, benefits, and other factors that may influence your decision, so you can select a plan that’s right for you and your family. You can purchase your health insurance right on the website, too. All health insurance plans you see on the marketplace will have to explain what you get and what you’ll pay, in plain language.

    Anyone who purchases health insurance on their own can use the marketplace. If you are eligible for financial assistance from the government, you may be required to purchase your health insurance on the marketplace, though many states also will allow you to use your financial assistance from the government to purchase a plan directly from a health insurance company.

    Health Insurance Marketplaces open October 1, 2013. If you purchase a plan and make your first premium payment on or before December 15, 2013, your coverage will start January 1, 2014.

    You’ll have until March 31, 2014, to buy a health insurance plan for 2014 - but the later you buy your health insurance, the later your coverage will begin. Your coverage starts after you purchase a plan and make your first premium payment.

    The marketplaces reopen again in October 2014 for plans taking effect in 2015.

  • What are the levels of coverage on the exchanges?

    If you shop for health insurance on an exchange you’ll notice another way to compare plans. Plans you see there are assigned a bronze, silver, gold, or platinum coverage level. The levels were created by the government for use on the exchanges.

    The levels aren’t types of plans, like HMOs or PPOs. They’re an “apples to apples” way to compare plans from multiple health insurance companies available on the exchanges. For example, you might want to compare two different silver level HMO plans, or compare a gold HMO plan with a gold PPO plan.

    The levels don’t mean a plan is “good” or “bad.” They tell you the average percentage of your essential health benefits the plan will cover during the benefit year. (Remember, all plans on the exchanges must include the essential health benefits, but you may pay out-of-pocket when you receive some of the services.) You may also want to compare premiums and out-of-pocket costs of plans within the same level.

  • How does the "80/20" rebate work?

    If you buy your own health insurance, your insurance company must give a rebate if it spends less than 80% of the premiums it collected on care and quality improvement. This new requirement is often called the "80/20 rule."

    If you are eligible for a rebate, you may get a check in the mail or you may get an automatic discount on your future premiums. If you paid your premium with a credit or debit card, your insurance company may deposit your rebate into the bank account you used to pay the premium.

    Important to remember: your insurance company’s performance on the 80/20 rule may change from benefit year to benefit year. So getting a rebate one benefit year doesn’t mean you’re guaranteed a rebate the following benefit year.

Definitions

Children’s Health Insurance Program (CHIP)

CHIP provides health insurance to children in families with incomes too high to qualify for Medicaid, but who can’t otherwise afford private health insurance.

Coinsurance

Your share of costs for a covered service. This generally applies after you meet your deductible. For example, once you meet your deductible, you might pay 20% and your health insurance plan pays 80%. But once you meet your plan’s annual out-of-pocket maximum, your plan pays 100% of your costs for covered services.

Copay (copayment)

A fixed amount (for example, $15) you pay for a covered healthcare service, usually when you receive the service. The amount can vary by the type of covered healthcare service.

Deductible

The amount you pay for medical services before your health insurance plan begins to pay. Not everything you pay (such as your premium and copay) counts toward your deductible. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered healthcare services subject to the deductible.

Essential health benefits

A package of items and services that any health insurance plan sold directly to individuals in 2014 must include, for medically necessary care:

  • Ambulatory patient services (care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment (both counseling and psychotherapy)
  • Certain prescription drugs
  • Rehabilitative and habilitative services and devices (these help people recover their mental or physical skills)
  • Laboratory services
  • Preventive and wellness services, and chronic disease management
  • Pediatric services (including both dental and eye care)

You may be responsible for some out-of-pocket costs on these items and services.

Plans may include more than these essential health benefits; and plans purchased through your employer may offer these benefits, too. For details, check your plan.

Grandfathered health insurance plan

A health insurance plan that has existed since March 23, 2010, and has not changed significantly. Grandfathered plans count as health insurance under the new law – but grandfathered plans are not required to include all of the healthcare law’s new benefits and protections. Check with your health insurance company to find out if your current plan is grandfathered, and how its features compare to the new law.

Health Insurance Marketplace

The marketplace – you may hear it called an "exchange" – is another way to shop for health insurance, with a website where you can compare plans from multiple health insurance companies and find out if you qualify for financial assistance from the government. Tools on the marketplace allow you to compare plans by price, benefits, and other factors that may influence your decision, so you can select a plan that’s right for you and your family. You can purchase your health insurance right on the marketplace, or on your local insurance company’s website, too. All health insurance plans you see on the marketplace will have to explain what you get and what you’ll pay, in plain language.

Anyone who purchases health insurance on their own can use the marketplace. If you are eligible for financial assistance from the government, you may be able to purchase a plan directly from a health insurance company, in addition to purchasing on the marketplace.

Health Savings Account (HSA)

A medical savings account for certain out-of-pocket medical expenses. You do not pay taxes on the money you save to your HSA. You must be enrolled in a high-deductible health plan to use an HSA. Any money you have not spent by the end of your coverage period remains in your account after the end of the benefit year, so you can still use it in the future.

Medicaid

A health insurance program run by the state governments that provides health coverage for some low-income adults, children, pregnant women, the elderly, and people with disabilities. Medicaid programs must follow federal guidelines, but they vary from state to state.

Network

The doctors and hospitals contracted with your health insurance company to provide covered medical care for your specific health insurance plan. Some plans will only pay for care you receive within the network. Others allow you to go outside the network, but you will pay more for your care than if you stayed in the network.

Out-of-pocket

The money you pay out of your own pocket when you get medical care – visiting the doctor or filling a prescription, for example. Out-of-pocket costs include deductibles, coinsurance, and copayments.

Your health insurance plan has a cap on the total out-of-pocket costs you pay in a benefit year. This limit is often called an out-of-pocket maximum.

Premium

The fixed amount you pay each month to have health insurance. You pay your premium even if you don’t receive any medical care.

Primary care physician

A doctor who cares for your general medical needs, like routine checkups and vaccinations. Primary care physicians can also help coordinate your care among specialists and other types of healthcare professionals.

Some health plans may require you to select a primary care physician. Under these plans, if you need to visit a specialist, for example, your primary care physician must refer you first.

Specialist

A healthcare professional who is an expert in a specific branch of medicine. Some health plans may not allow you to go directly to a specialist. They may require you to get a referral from your primary care physician.

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    WHAT THE

    NEW HEALTHCARE LAW

    MEANS FOR YOU


    Important Dates, New Security, New Choices


    Dates to Know

    December 15, 2013

    Deadline for signing up for coverage that starts January 1, 2014

    January 1, 2014

    New health insurance coverage takes effect as early as January 1, 2014.

    March 31, 2014

    Enrollment for health insurance in 2014 closes March 31, 2014.

    New Security for Millions of Americans

    The healthcare law creates a new way for you and your family to get health insurance and adds financial stability for an estimated 30,000,000 currently uninsured Americans by introducing new rights and protections. Depending on your income and family size, you may qualify for help paying for insurance. If you think you can’t afford insurance on your own, find out how you may be eligible for financial assistance from the government.

    New Choices, New Options

    The new healthcare law – the Affordable Care Act – makes new choices available for you, your family, and your wallet. Health insurance “exchanges” (for example, the Health Insurance Marketplace run by the federal government) open October 1, 2013, with choices for individuals and families, including those who might not have had health insurance before. Health insurance you buy on the exchanges kicks in as early as January 1, 2014.

    New changes include:

    • If you think you can’t afford health insurance, you may be eligible for financial assistance from the government.
    • If you have a pre-existing medical condition like asthma, heart disease, or cancer, you can’t be denied health insurance or charged more for it.
    • If you have children, they can stay on your health insurance until they turn 26, even if they’re married or living out of your house.
    • You may get help with prescription drug costs.
    • If you buy your own health insurance, your health insurance company must give a rebate if it spends less than 80% of all of the premiums it collected on care and quality improvement.

    These are just a few of the health insurance changes on the horizon. Learn more about what these changes mean and what you’ll need to do in the AskBlue Healthcare Law and You section.

    Find out more about health insurance for you and your family.

    Get Started
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