Tag: Health Care

There are a lot of special terms in the health insurance world, and they can be difficult to understand. We’re here to help you make sense of terms you see on Healthcare.gov.

Watch the video and scroll down for more terms defined.

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.

Catastrophic Health Plan
The premium amount you pay each month for healthcare is generally lower than for other plans, but the out-of-pocket costs for deductibles, copayments and coinsurance (see terms defined below) are generally higher. To qualify for a Catastrophic plan, you must be under 30 years old OR get a “hardship exemption” or “affordability exemption” (the Marketplace determines that you are unable to afford health coverage because of the cost of the health insurance plan offered to you is too expensive or you have a financial hardship circumstance).

COBRA
A federal law that may allow you to temporarily keep health coverage after your employment ends. If you choose COBRA coverage, you pay 100% of the premiums, including the portion that your employer used to pay, plus a small administrative fee.

Coinsurance
Like a copayment (see next term), but in the form of a percentage of the cost of a healthcare service (e.g. you pay 20% of the cost of a visit or procedure).

Copayment
A set amount that you pay for a medical service or item, like a doctor’s visit. The insurance company covers the rest.

Deductible
The amount you have to pay for covered health care services (e.g. doctor and hospital visits, labs, etc.) before your health insurance or plan begins to pay. Often, the health insurance company will only pay a percentage of the costs after you reach your deductible. If you think you will need a lot of healthcare services in a year, you should look for plans with a low deductible.

Metal Categories of Health Plans
In addition to catastrophic plans, Healthcare.gov plans come in four metal categories: Bronze, Silver, Gold and Platinum. Bronze plans are usually best for individuals who have few health needs but want to be prepared in case of an emergency. Bronze plans have the lowest monthly premiums, but they have a high deductible. Gold and Platinum plans are often best for people who use a lot of health services. They have the highest monthly premiums, but each visit to the doctor and each prescription will have a low copay/coinsurance. Plans in all metal categories provide free preventive care (for example, a yearly wellness visit to your doctor).

Silver plans are ideal for individuals/families with income less than 250% FPL. If you select a Silver plan, you will receive cost sharing reductions, which means your out of pocket costs (deductible, coinsurance and copays) are also subsidized and may be very low.

Network
The doctors, hospitals and suppliers your health insurer has contracted with to deliver health care services to their members. Ask a healthcare provider if they accept your insurance before you visit. If you go out of network, your care will be more expensive.

Out-of-pocket Maximum
Usually a larger number than your deductible. This is the absolute maximum amount of money you will have to spend in the year on healthcare costs. After you reach this amount, the health insurance company will cover all services 100%.

Plans and Prices Tool: https://www.healthcare.gov/see-plans/#/ 
Saves you time! This tool allows you to see what plans are available in your area and how much financial assistance you qualify for before you fill out an application. 

Pre-existing Conditions
A health problem, like asthma, diabetes, or cancer, that you had before the date that new health coverage starts. Insurance companies can’t refuse to cover treatment for your pre-existing condition or charge you more.

Premium
The amount you pay for your plan each month.

Premium Tax Credit
The “subsidies” that lower the cost of your monthly premiums. You can take the premium tax credits in advance to lower your monthly cost, or you can take them as a refund at tax time.

To look up more key terms, visit the Healthcare.gov glossary.

Charlotte Center for Legal Advocacy’s health insurance navigators help families and individuals choose plans that are best for them within the Health Insurance Marketplace implemented under the Affordable Care Act (ACA). During this Open Enrollment Period, navigators have received calls and questions from Cabarrus, Mecklenburg and Union County residents about the household income section of the Healthcare.gov application. With this year’s pandemic and economic uncertainty, many have lost or changed employment and are struggling to estimate their income.

Listed below this video are some helpful tips and general guidelines. More of what to (and not to) include is available at charlottelegaladvocacy.org/getcovered.

Important points:

• You must estimate your projected income for the upcoming year.
  • If you are unemployed, it may be difficult to do this. Estimate how much you would make if you returned to your previous job.
  • If you don’t have a set salary or wages (for example, if you are a freelance worker, seasonal worker, or run your own business), it will be easier to estimate your income if you have a copy of your tax return from last year on hand.
  • If you are self-employed, you should input your net income. Click here for more help estimating your self-employment income.
  • If your income is very low or if you are unemployed, and you or a family member falls into one of the following groups, you may qualify to receive Medicaid:
    • children under 21
    • pregnant women
    • women with breast or cervical cancer
    • primary caretaker of a child under 18
    • individual in foster care when turned 18
    • individuals aged 65 or older
    • blind or disabled individuals
    • people in need of long-term care
    • people receiving Medicare
• You must report changes in income.
  • During the year, you must go back into your application to report if your income goes up or down. This will keep your monthly premium at a manageable price and help to reduce the amount of financial assistance you may have to pay back, if any at all.
• You can receive financial assistance.
  • Estimating your income as accurately as possible allows the Marketplace to determine your eligibility for financial assistance.

Be sure to include:

• Anticipated changes in income
  • Consider these questions: How might your income change in the coming year? Are you expecting business to improve or worsen? Will you be getting a raise? Work more hours? Get a seasonal job? Will another household member get a job? Will you gain or lose a dependent?
• The anticipated income of all household members
  • If another person in your tax household has health coverage through a different plan or program, you still need to include their income on your application. Marketplace financial assistance is based on the income of all tax household members. You will be able to clarify on the application which household members do not need health coverage. Tax household members not applying for coverage are not required to provide any other information except income information (e.g. They do not have to provide a Social Security Number).
• Some disability-related income
  • Only include Social Security disability payments when estimating your income for next year. Do not include Supplemental Security Income, only Social Security retirement or disability payments.
• Income from investments
  • Things like stocks and bonds.
• Alimony
  • Include only if your divorce or separation was finalized before January 1, 2019.

Do NOT include:

• Self-employment expenses
  • Subtract any self-employment expenses from your estimated income.
• Some disability-related income
  • Do not include Veterans’ disability income payments, Supplemental Security Income (SSI) payments, and workers’ compensation payments when estimating your income for next year.
• Social Security payments for applications that have not yet be approved
  • You can update your Marketplace application later next year if your application is approved.
• Alimony
  • Do not include if your divorce or separation was finalized on or after January 1, 2019.
• Child support

Free appointments with a local navigator can be made using the statewide appointment hotline at 1-855-733-3711, or online at www.ncnavigator.net. Appointments are filling quickly!

More Resources:

More information on how to report your income: https://www.healthcare.gov/income-and-household-information/how-to-report/

And on what to include: https://www.healthcare.gov/income-and-household-information/income/

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.