Like all contracts, reading the fine print is essential to understand thoroughly what you are purchasing. Health insurance is no different. You may be signing up for a coverage that seems promising but in reality, it probably was not part of the list in the first place. It pays to be aware what kind of services you would be needing to pay for when availing health insurance in order for you to make smart choices.
Options for Coverage
There’s no need to worry if you are covered health insurance by your employer. However, once you leave, so will your health insurance. If you are in this position, there are a number of ways for you to get back your coverage on health insurance:
1. COBRA Coverage
As declared in the COBRA (Consolidated Omnibus Budget Reconciliation Act), you have the choice to keep your health coverage by your former employer for up to 36 months. That’s 2 years and a half. However, this is a costly way to maintain insurance as you will be independently funding the premium. You will not be sharing your expenses with your former employer.
2. Help From Your Spouse
If your spouse is employed, in some cases they can add you in on their insurance as well.
3. Family Policies / Private Individual
You can look into some private insurance plans directed towards individuals or families. Blue Cross, Aetna, and Cigna are some of the companies who create these types of plans.
Each state has a designated healthcare exchange or marketplace run by the states themselves. If you’re a bit new to this, it is advisable for you to seek help from the expertise of a navigator online or in person. They will assist you with the options suitable for you. Check out healthcare.gov if you want an easy site navigator start with.
No luck with the four options above? You can try enrolling for Medicaid. It is state-governed and is directed for those specifically with low income. That being said, Medicaid is not for everyone but if you qualify for their criteria, you might want to look into this further.
One very important thing to keep in mind is the enrollment period. This is a crucial time where people can weigh in the benefits and coverages of different health insurance plans so they can choose the perfect insurance policy. If you happen to miss the enrollment period, worry not. There are special periods for those with qualifying instances. For example, if you lose your job, get pregnant, or are in deep financial trouble, you have a 60-day grace period to apply for a special enrollment. After which, should you miss this one again, you would have to wait until the next regular enrollment period.
For the case of Medicare, you can still apply within a time window of 7 months surrounding your 65th birthday. If you have plans to change your Medicare plans, the enrollment period is from October – December.
Before the Affordable Care Act (ACA) was passed, health insurance companies and providers had the autonomy to decide what services to cover or not.
After the ACA was implemented, individual and small group plans were required to cover the standardised 10 essential benefits ACA created. This was also made available to companies with under 50 employees. Some of these essential benefits included certain health care needs such as doctor visits and hospitalizations.
For the larger group market, different rules apply. Preventive care is part of the essentials. It became mandatory for larger companies with 50 or over employees to provide health insurance that offers minimum value. They are not required to cover the 10 essentials declared for smaller groups. Either way, most bigger companies provide for them anyway.
As of 2014, it became compulsory for Medicaid and Medicare health insurance plans to cover the 10 essential benefits.
A friendly reminder to make health insurance window shopping easier for you – list down services you might need for your health insurance plan. Call your insurance company if the services you listed down are covered fully or partially.
What’s Not Covered
1. Travel Vaccines
These are not to be confused with general health vaccines. Tetanus shots or flu vaccines are considered part of preventive care and are generally covered by insurers. However, if you will be flying abroad, there are some preventive shots that might not be provided. Some examples are Typhoid or Yellow Fever vaccines.
2. Alternative Therapies (Acupuncture, Homeopathy, etc)
Some are actually covered by certain health insurance plans. It all depends on the state you’re in and how it defines the essential package. For the under-65 market, you would not usually find alternative therapies as part of the essentials. For instance, chiropractic treatment. In most states that do have this as a required policy, they put a cap on how many visits a patient can do. They usually range from 10 to 30 visits per year.
3. Cosmetic Surgery
It’s pretty self-explanatory why this is not deemed as part of the essentials. However, if you will be needing reconstructive surgery, count that as medically necessary as it is not for cosmetic purposes but for health purposes.
4. Nursing Home Care
This service is usually covered by long-term care insurance and Medicaid. You cannot find this service covered by Medicare and commercial health insurance plans. However, there are exceptions to the rule.
Medicare requires for the patient to have a three-day inpatient hospital care prior to their stay in the skilled nurse facility. In this event, Medicare can allow coverage for skilled nursing.
5. Dental, Vision, and Hearing
If you need these services in a plan, you would usually have to buy separate plans as most providers do not offer these three simultaneously in a single plan. Keep in mind that these are not under the regulation of ACA which means requirements for coverage are not specific.
6. Weight Loss Surgery
Most plans do not cover bariatric surgery. But there are 23 states that consider some sort of coverage for weight loss surgery as part of the essentials. This could mean that there are certain weight loss procedures that are covered, and there are some that are not.
7. Preventative Tests
There are many tests that are deemed necessary and covered by insurance. Three government agencies get to determine whether or not a specific service can be declared as preventive care. Should there be lacking evidence, it will not be included as fully covered.
8. All Medications
Prescription medications are actually part of the essentials, so that’s good news right there. However, going back to having to read fine prints, insurance companies are not required to cover all drugs. Generic drugs most likely will be covered more often than branded ones.