Category: Health Insurance

You took the step to enroll for health insurance coverage using Healthcare.gov. Congratulations! You’ve joined more than 31 million people who have the peace of mind of knowing they are covered with access to preventive health care and life-saving screenings.

Take advantage of free services.

Preventive health services are included in every Healthcare.gov plan and are free. They are routine health care procedures such as screenings, check-ups, and counseling to prevent illness and other health problems.

All Healthcare.gov plans are required to cover preventive health services 100%. This means that insurance companies cannot charge you a copay or coinsurance to get this type of medical attention. For example, an annual check-up, immunizations, children’s vision screenings, contraception and well-woman visits are free. You’ll just need to show your health insurance card at your doctor’s office. Get specific lists of preventive services for adults, women and children.

Preventive services are free only when you get them from a doctor or other provider in your plan’s network. (A network is the facilities, providers and suppliers your health insurance company has contracted with to provide health care services.) Talk to your doctor about taking advantage of these free services to keep you and your family healthy.

Look at the Summary of Benefits and Coverage.

To understand your plan better, and to be prepared in case of illness or an emergency, read the Summary of Benefits and Coverage that comes with your plan. Log in to your Healthcare.gov account or call your health insurance company to get a copy. 

This document will give you a snapshot of your possible costs throughout the year and includes examples of common medical events. For example, it will explain how much a hospital visit or prescription drugs will cost you.

Know where to go for care. 

You can get health care at many different places, including the emergency department when you’re injured or very sick. But it’s best to get regular care from a primary care provider (often a doctor at a family medicine clinic). Primary care providers work with you to make sure that you get the right services, manage your chronic conditions and improve your health and well-being. It might take more than one visit to figure out if a provider is right for you, so it’s important to be proactive and start your search now.

If you aren’t sure how to find a doctor in your area, your health insurance company’s website is a good place to start. If you have a health insurance plan in the Charlotte area, use the following provider search tools:

• Aetna
• Ambetter
• Blue Cross Blue Shield
• UnitedHealthcare

Or, if you know of a doctor that a friend or family member recommended to you, you can call that doctor’s office to see if they accept your health insurance plan. Remember, your care will be a lot cheaper if you go to a doctor in your health plan’s network.

Check out this guide for more great tips on how to make your health insurance work for you.

If you have questions about your coverage, or your income or health care needs change at anytime, call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

As a consumer on the Health Insurance Marketplace (Healthcare.gov), you have the right to appeal decisions that are not in your favor. There are two types of appeals. The first is an appeal of a Marketplace decision (generally a decision on your eligibility to purchase a plan on Healthcare.gov). The second is an appeal of an insurance company’s decision (usually a decision of whether the company will cover a particular drug or surgery).

Appealing a Health Insurance Marketplace (Healthcare.gov) decision

You have the right to appeal any of the following decisions:

• Denial of Advanced Payments of the Premium Tax Credit (APTCs) or Cost Sharing Reductions (CSRs)
• Amount of APTCs or CSRs
• Adjustment in APTCs or CSRs at end of 90-day inconsistency period
• Denial of eligibility to enroll in Marketplace coverage
• Denial of a special enrollment period
• Termination of Marketplace coverage
• Denial of coverage exemption
• Denial of eligibility for Medicaid/CHIP

Important note about eligibility appeals: If the Marketplace says that you are ineligible to buy a plan on Healthcare.gov, you have 90 days to appeal. Learn more about filing an eligibility appeal here.

Fill out appeal forms online here. If you want a family member or another person to represent you in your appeal, find out how to appoint an authorized representative here. After you have submitted your appeal, you can check on the status of your appeal by calling the Marketplace Appeals Hotline (855-231-1751).

How we can help: A Health Insurance Navigator can help you gather information to file your appeal, and our staff can represent you in your appeal at no cost. 

Appealing a health insurance company decision

If your health insurance company refuses to pay for a procedure or a medication, you have the right to appeal. Your health insurance company is required to let you know why they denied coverage, and they must provide you with information on how to appeal.

There are two types of insurance company appeals: Internal appeals and external reviews.

Internal appeals are reviewed by the health insurance company itself. You can file a request for coverage (also known as a claim) either before or after receiving medical attention. If your health insurance company denies coverage of your claim, you must file your appeal within six months of receiving notice that your claim was denied. Follow the instructions that the insurance company includes with their denial. Click here for more information on internal appeals. 

External reviews are the last option to appeal an insurance company’s denial (outside of the legal system), and they are processed by the North Carolina Department of Insurance. External reviews in NC are free. You can reach the Department of Insurance at 855-408-1212, or you can visit their website to request an external review. Click here for more information on external reviews.

Health Insurance Navigators can help you appeal a health insurance company decision and navigate the appeal process with the NC Department of Insurance. 

To get free help from a Charlotte Center for Legal Advocacy Health Insurance Navigator, call 980-256-3782. You can also book an appointment by visiting ncnavigator.net.

Learn more about how to get covered, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

Starting July 1, 2021, individuals may be eligible for additional savings and lower costs on their 2021 Healthcare.gov (Health Insurance Marketplace) plan if they received, or were determined eligible to receive, unemployment compensation in 2021.  

What does this mean for you?  

If you or your spouse received unemployment income for at least one week in 2021, your whole household may be eligible for a higher tax credit that may cover your monthly premium in full, regardless of your household’s income. In addition, you may be eligible for higher cost-sharing reductions to lower your deductible, copays and out of pocket costs if you select, or currently have, a Silver plan on Healthcare.gov. (See the difference between Bronze, Silver, Gold and Platinum plans in our Basic Health Insurance Terms blog post.)

What do I need to do?  

If you are currently enrolled in a Healthcare.gov plan, and you or your spouse received at least one week of unemployment compensation in 2021, you must report a change on your Healthcare.gov application and add unemployment compensation as part of your income. Even if you already reported that you received (or are receiving) unemployment, you will need to update your application to get these enhanced benefits. You can reselect your current plan or change plans if you want to.  

If you are not enrolled in a Healthcare.gov plan, you can apply to see if you qualify for these enhanced subsidies under the Special Open Enrollment Period open now through Aug. 15, 2021. (If you complete an application and select a plan before July 31, 2021, your plan will start on Aug. 1, 2021.) See the Get Covered section of our website to learn more and book an appointment with a Health Insurance Navigator.  

If I only received one week of unemployment and I have no income now, would I still qualify?  

Yes! You may be eligible to receive enhanced benefits even if you have no income at the moment and your unemployment compensation already expired.  

Learn more about how to get covered on Healthcare.gov, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

All Healthcare.gov plans are required to cover preventive health services 100%. Additionally, these plans are required to include 10 types of health services—called Essential Health Benefits. Keep reading to learn more about these services below.

Preventive Health Services

Preventive health services are routine health care procedures, like screenings, check-ups and counseling to prevent illness, disease and other health problems.

This means that insurance companies cannot charge you a copay or coinsurance to get this type of medical attention. For example, immunizations, children’s vision screenings, contraception and well-woman visits are free. Get specific lists of preventive services for adults, women and children.

Preventive services are free only when you get them from a doctor or other provider in your plan’s network. (A network is the facilities, providers and suppliers your health insurance company has contracted with to provide health care services.) Talk to your doctor about taking advantage of these free services to keep you and your family healthy. 

Essential Health Benefits

While most of these services won’t be free, plans will pay for at least a portion of the costs of these services.

• Ambulatory patient services (outpatient care you get without being admitted to a hospital)
• Emergency services
• Hospitalization (like surgery and overnight stays)
• Pregnancy, maternity, and newborn care (both before and after birth)
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
• Prescription drugs
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills)
• Laboratory services
• Preventive and wellness services, as well as chronic disease management
• Children’s oral and vision care

Learn more here: https://www.healthcare.gov/coverage/what-marketplace-plans-cover/ 

Learn more about how to get covered on Healthcare.gov, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.