The Affordable Care Act (ACA), also known as ObamaCare, has given millions of Americans access to new insurance policies. These policies include a number of benefits such as essential health coverage, rules against denying coverage or charging more for pre-existing conditions, and more. To get the most out of your insurance plan, it is essential to fully understand it.

To take full advantage of your health insurance coverage, you first want to contact the insurance company to ensure that your policy is fully in place and that your first payment has been received. Technical issues in some states have resulted in such problems as consumer payments not being applied to coverage; it’s important to know that your coverage is secure before a health problem occurs.

Understand the Plan Network

In order to make the best use of your insurance, be sure that you understand the health provider network it covers. In fact, the providers that are included should be an important part of choosing a plan. Because this information is not readily available in the Marketplace, you will probably need to call your key providers to find out in what plans they participate. Remember that pharmacies are providers too, and you will want to make sure yours is in-network to keep costs low.

  • In-network means that the doctor/provider and the insurance plan have agreed to a rate of pay for the services offered. You can go to this provider and pay the regular copayment or deductible that the plan requires – the plan will pay the rest.
  • Out-of-network means that the provider has not agreed to the plan’s pay rate, or the plan has chosen not to accept the provider into the network. Either way, you will be responsible for a larger portion of the costs, or the plan may not cover any costs at all. It’s important to choose a health insurance plan where your key, regular providers are in-network.

Understand Your Health Needs

Some younger, healthier Americans question whether they need health insurance at all. They don’t expect to get sick or have any particular need for doctors or hospitals. If you are in this situation, you may find that you want a plan with lower monthly premiums but higher cost-sharing, such as copayments and deductibles. You’ll pay more if you do need the health services, but you’ll pay less if you stay healthy over time. It’s understandable to not want to pay a monthly premium for a service you may not use. However, accidents do happen and unanticipated health problems often arise, and this should be taken into consideration when deciding to pay the penalty or purchase health insurance.

Other Americans face health problems that are more serious or chronic. If you find yourself in this category, you’ll want to carefully evaluate the cost of the plans available to you. The plan that offers the lowest monthly payment may actually turn out to be the most expensive plan if the deductibles and copayments are high. You will likely find that it’s better to pay a bit more each month in order to be able to afford the regular treatment you need.

Understand Prescription Coverage

As mentioned earlier, pharmacies are considered medical providers and may or may not be covered by a particular insurance plan. This can change the cost of your prescription dramatically. In addition, health insurance plans have lists of approved drugs that they will pay for. This list is called a formulary and is available on the insurance company’s website or by calling the insurer. You will notice that generic drugs are less expensive than their name brand counterparts. If they work well for you, generics can be a very cost-effective option.

If you have concerns about a medication not being covered, sometimes new enrollees can get a one-time refill from the insurer and then discuss alternatives with their doctor. You can also try to go through the insurer’s drug exception process, which may let you get a drug that is not on the list of approved medications. Every plan’s process is different, so contact your insurer for specifics.

Understand Your Essential Health Benefits and How to Use Them

In addition to prescription coverage, health care plans sold through the Marketplace must provide nine additional essential benefits as defined under ObamaCare. There are a number of ways that new enrollees can make use of these new health benefits:

  • Emergency services

If you feel you are ill and require emergency care, under the ACA, your emergency visit to a doctor or hospital does not require pre-authorization and you will not be charged additional fees for receiving medical attention outside of your network.

  • Hospitalization (including surgery)

This essential benefit dictates that non-elective surgeries and hospitalization must be covered by your plan. Individuals may be subject to out-of-pocket costs, depending on their plan’s cost-sharing requirements.

  • Maternity and newborn care

In addition to covering hospitalization and birth events as part of the maternity and newborn care benefit, under the ACA several wellness services can be provided to expectant mothers, new mothers, and babies without cost sharing. Some of these wellness services include lactation support and counseling, renting breastfeeding equipment, and screening for gestational diabetes.

  • Mental health and substance use services, including counseling and therapy

Before the advent of the ACA, mental health and substance abuse services were not always covered to the same level as medical services by many plans. Now, marketplace plans must cover mental health and substance use services, including counseling. However, be mindful of whether or not your counselor participants in your insurance plan.

  • Outpatient care

Also known as ambulatory services, outpatient care refers to services that do not require a hospitalization, such minor surgeries and diagnostic tests like X-rays and MRIs.

  • Access to rehabilitative/habilitative programs and devices to aid in recovering from injuries, disabilities, or chronic conditions

Some examples of rehabilitative services include physical and speech therapy for stroke victims, or individuals recovering from an accident. Habilitative programs would allow a person with a speech impediment to take advantage of speech therapy. Physicals, immunizations, and care for chronic conditions such as diabetes and asthma fall under this category, as well.

  • Laboratory services

This benefit calls for the laboratory services associated with preventive care, including blood sample and biopsy analyses.

  • Preventive and wellness care

Marketplace plans must cover preventive and wellness services without cost-sharing when performed by an in-network provider. This includes a routine pap smear, mammogram, or breast cancer screening for women and an annual prostate exam for men.

  • Pediatric wellness care (including dental and vision services)

Routine checkups for children and well-baby care are covered by this benefit. Additionally, although dental coverage is not considered an essential health benefit for adults, children under age 19 can receive dental care, allowing them access to routine checkups and corrective dental appliances that are a medical necessity.

Having a new insurance plan, especially if you haven’t had health insurance coverage before, can be both overwhelming and comforting. It’s reassuring to know that you have access to health care should a health emergency arise, as well as preventive care. However, it’s also important to make sure you’ve reviewed the plan’s network, your health needs, and important prescription drug information. By following these steps, you will have a greater understanding of your health insurance plan.

 

Sources:

https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/

https://www.healthcare.gov/what-if-i-have-a-pre-existing-health-condition/

http://marketplace.cms.gov/getofficialresources/publications-and-articles/contact-health-plan.pdf

https://www.healthcare.gov/using-your-new-marketplace-coverage/

http://www.forbes.com/sites/scottgottlieb/2013/12/09/no-you-cant-keep-your-drugs-either-under-obamacare/

https://www.healthcare.gov/glossary/essential-health-benefits/

https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/

http://www.aarp.org/health/health-insurance/info-08-2013/affordable-care-act-health-benefits.2.html