When people sign up for a new health insurance plan—whether it’s an employer-sponsored plan or one purchased through the Affordable Care Act (ACA) exchange—they are often confused about when coverage starts, what services are covered, and how much they will need to share in the cost of care.
The Kaiser Family Foundation recently compiled a list of seven takeaways from stories about people who ended up paying large out-of-pocket expenses for medical care. Reviewing these tips can help health plan enrollees better understand their coverage and avoid unexpected financial surprises.
1. Most insurance coverage doesn’t start immediately
Many new plans include waiting periods, so it’s important to maintain continuous coverage until your new plan takes effect. Usually, health insurance starts on the first of the month and ends on the last day of the month.
There are special circumstances when someone loses job-based health coverage. In that case, they may elect COBRA or purchase a plan through the ACA marketplace.
- With COBRA, once payment is made, coverage applies retroactively—even for care received while someone was temporarily uninsured.
- Losing employer coverage qualifies someone for an ACA Special Enrollment Period, which generally allows them to enroll in a Marketplace plan up to 60 days before or 60 days after their employer coverage ends. If someone enrolls before their job-based coverage ends, their new plan can usually begin right away and help prevent a gap in coverage.
- If someone enrolls after their job-based coverage ends, Marketplace coverage usually begins on the first day of the month after enrollment, so they could experience a short coverage gap before the new plan starts.
2. Check coverage before checking in
Some health plans include restrictions that may not be obvious at first. These restrictions can affect coverage for services such as contraception, immunizations, and cancer screenings.
Before receiving care, enrollees should contact their insurance company (or for job-based insurance, their human resources or retiree benefits office) to confirm coverage. Ask whether there are exclusions for the care you need, whether there are limits per day or per policy period, and what out-of-pocket costs you should expect.
3. “Covered” doesn’t always mean insurance will pay right away
It’s important to read the fine print about network gap exceptions, prior authorizations, and other insurance approvals. These requirements may apply only to certain doctors, services, or dates.
In addition, even if a service is covered, the insurance company may not pay for it until you have met your deductible or other cost-sharing requirements.
4. Get estimates for non-emergency procedures
Before scheduling a non-emergency procedure, patients may be able to compare prices among different providers. Request written estimates whenever possible.
If the cost seems too high, it may be possible to negotiate the price before receiving care, or find an alternate provider.
5. Location matters
The cost of care can vary significantly depending on where services are performed.
For example, if blood work is required, ask your doctor to send the order to an in-network lab. Sometimes a doctor’s office affiliated with a hospital system will automatically send samples to a hospital lab, which may result in higher charges if the lab is out of network.
6. When hospitalized, contact the billing office early
If you or a loved one is admitted to the hospital, speaking with a billing representative early in the process can help prevent confusion later. Consider asking questions such as:
- Has the patient been fully admitted, or are they under observation status?
- Has the care been classified as “medically necessary”?
- If a transfer to another facility is recommended, is the ambulance service in-network—or can one be selected?
7. Ask for a discount
Medical charges are often higher than the rates insurers typically pay, and providers frequently expect some level of negotiation. Patients may also be able to negotiate their own bills. In addition, uninsured or underinsured patients may qualify for self-pay discounts or financial assistance programs such as charity care.
If you need assistance with your health insurance in California, contact Benefits By Design Insurance Services in San Diego. www.benefitsbydesignca.com or email admin@benefitsbydesignca.com.
