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Managing Your Healthcare Plan

Under what circumstances can my coverage be canceled?

Before the Affordable Care Act’s implementation, health insurance plans were canceled all the time. The difference now has to do with the acceptable reasons for
the cancellation.  As indicated previously, your insurance plan may be canceled for any of the following reason:

The plan did not meet the standards outlined in the ACA rules.

  • The plan was previously grandfathered into the system but lost its grandfathered status because it made unauthorized changes.
  • Your provider decided to discontinue the plan that covers you and your family. 
  • You committed fraud in applying for coverage

Can my insurance provider stop offering my policy?

Individual policies are generally renewed at the end of the twelve-month contract. As long as your insurer has met the following requirements, it can stop offering
your system:

  • A written notice must be sent to each covered individual within ninety days. 
  • Covered individuals must be offered the option to buy any other individual policy offered by the insurer to in dividuals in that market.
  • All individuals must be treated the same.

Can I shop on the exchange even if my employer offers healthcare?

Of course, you can. I encourage it. You might even be able to enlighten your employer about what other options are out there that offer more choices at a lesser cost. If you decide to leave your plan and purchase coverage on the Marketplace, you may not qualify for some of the benefits you might be receiving on your employer-based pan or vice versa.

What are private exchanges?

These are healthcare exchanges created by private companies. They usually operate online and through human advocacy and are designed to help you find the right plan for you and your family. If your project has not been canceled and has been grandfathered in, or it may be noncompliant, you still exist under a private exchange.  This means you are exempt from the ACA imposed penalty for not having insurance.

The Four types of plans in the public Marketplace exchanges

The plans are named for metals, Bronze, Silver, Gold, and Platinum.
Bronze Plan: This is the least expensive, covering about 60 percent of your medical expenses 
Silver Plan: This plan will cover about 70 percent of your medical expenses. 
Gold Plan: The Gold healthcare plan pays about 80 percent of your medical cost. 
Platinum Plan: This is the highest plan in terms of premiums.

Open Enrollment Period

This is when you can enroll in an insurance plan using either public or private Health Care exchanges. However, if you just began a new job and your employer is part of a group market such as the small business health option plan, you can enroll year-round.

Exceptions to the open enrollment dates

Yes. The following situations can create a sixty-day enrollment period for the individual market’s; unique and limited open enrollment periods. 

  • If you’ve experienced marriage, birth adoption or placement for adoption
  •  If you need new coverage as a result of a permanent move 
  • If you lose minimum essential coverage through your existing plan
  •  If you make mistakes during your regular enrollment that results in a loss of coverage
  • If your provider incurs a significant violation of the insurance contract
  •  If you’ve become newly eligible or newly ineligible for the premium tax credit’s advance payments or have experienced a change in eligibility for cost-sharing reductions.

Out of pocket maximum deductibles, coinsurance, and copays

The ACA requires that health plans consider deductibles, copays, and coinsurance all part of pocket maximums.
Let’s break this down a little further:

  •  Copays are the flat fees you pay to a provider for a specific service. 
  •  A deductible is what you must pay your provider for services before your insurance company starts paying.

Out of pocket maximum deductibles, coinsurance, and copays

The ACA requires that health plans consider deductibles, copays, and coinsurance all part of pocket maximums.
Let’s break this down a little further:

  •  Copays are the flat fees you pay to a provider for a specific service. 
  •  A deductible is what you must pay your provider for services before your insurance company starts paying.
Is everything covered if I hit my out of pocket maximum?

No. Unfortunately, you’ll still have to pay your health insurance premiums, any items not covered by your health plan, items your insurer deems to be not medically necessary, and any out of network expenses that are your responsibility.

What are the drug prescription benefits under the ACA?

You may have found that prescriptions were not covered under your health insurance plan or were considered to have a separate pocket maximum as well as a separate deductible. That’s now changed.  Any medications your doctor prescribes is also put toward your out-of-pocket maximum as well as your deductible. Thus prescription coverage is separated from medical coverage. Also, each state sets its list of covered medicines that every plan within that state must offer. This is called the formulary and specifies the bare minimum your health insurance must include. Your health insurance plan may provide more medicines. Most of these formularies have tiers that define their cost. Typically the higher the level, the higher the price:

  • Tier 1: Generic medicines
  • Tier 2: Preferred brand name medicines.
  • Tier 3: Nonpreferred brand name medicines
  •  Tier 4: Specialty medicines usually the most expensive.
What is a multi-state plan?

This is a health insurance plan administered by the U.S. Office of Personnel Management and covered within the exchanges marketplaces that allow families and small businesses to spread out over more than one state to select a health plan from the same health insurance issuer. This type of coverage is expected to expand into the Small Business Health Options Program exchange markets over time.