Plan Basics

Basics of Health Insurance Plans

Knowing how health insurance works really helps when it comes to getting the best medical care at the lowest cost.

What you need to know

Are you confused about health insurance? Most people are. A solid understanding of the basics will help you decide the best plan for your family.

All health insurance plans rely on provider networks. Some networks are very broad and give a lot of choices, while others are very narrow and limited.

♦ Using providers in your plan's network is the key to limiting your costs.

What's a provider network?

A provider network is a list of the doctors, other health care providers and hospitals that a plan has contracted with to provide medical care to its members. Some plans call these in-network providers, or simply preferred providers.

A provider who doesn't have a contract with your health insurer or plan is called an out-of-network or non-preferred provider. You'll pay more to see a non-preferred provider.

♦ Insurers generally can't require higher copayments or coinsurance if you get emergency care from an out-of-network hospital, no matter what type of plan you have.

• Your insurer has to judge whether it was an emergency by your symptoms, not your final diagnosis. If a reasonable person would think the symptoms needed immediate care, it counts. Chest pain that turns out to be heartburn still counts.

• Since 2022, the No Surprises Act also bans surprise bills for emergency care. An out-of-network hospital or ER doctor can't charge you more than your in-network costs.

Out-of-network providers may still bill you for planned, non-emergency care. This is called balance billing.

Do you accept my insurance?

This is a risky question.

Even if the doctor's office staff answers yes, it doesn't always mean the doctor you're planning to see is in your plan's network.

It could just mean they're willing to bill your insurance company.

You really need to confirm with your insurance company that the doctor or other provider is in your plan's network.

The best way is to call the customer service number on your insurance card and ask your insurer to confirm it.

♦ If your insurer's directory says a provider is in network and it turns out to be wrong, federal law says you generally should only pay in-network costs. Take a screenshot of the directory listing, and write down who you talked to and when.

How can I see if my doctor is in a network before I choose a plan?

• First, make a list of all the providers you use.

Remember that providers include health care professionals like doctors, psychologists and physical therapists, and health care facilities like hospitals and urgent care clinics.

Pharmacies, and clinics located inside pharmacies, are part of networks too.

• If you're considering individual insurance through Obamacare, you can compare plans offered on the Marketplaces before you enroll.

Start by visiting HealthCare.gov. The plans on the exchange will link to the insurance companies offering them.

Your state may use its own exchange instead of the federal one. The article Marketplace provides a list of state-run exchanges.

You also have the option of going directly to the websites of insurance companies you're interested in.

♦ Insurance companies may have different networks for different plans, so make sure you're searching the correct provider network for each specific plan you're considering.

You can also call the health insurance company's customer service number to check whether your providers are in the plan's network.

If you travel a lot, check whether the plan's network has providers where you might need care.

♦ If you're enrolling during open enrollment (November through mid-January), the online search lists aren't always reliable.

You should call the company's customer service number and ask them to confirm your provider will be in the plan starting next year.

♦ Just because the provider accepts the plan this year doesn't guarantee they'll accept it next year.

You need to confirm this, especially if keeping your family doctor or specialist is most important to you.

Why do some plans pay for network providers, but not out-of-network providers?

When a provider is a network provider for a plan, it means the provider offers services at prices that the provider and the plan have already agreed on.

The provider is obligated to accept the agreed reimbursement. This means you usually get services at a lower cost than someone without insurance, or someone whose plan doesn't include that provider in its network.

♦ All Marketplace plans are required to have provider networks with enough types of providers so members can get care without unreasonable delay.

For plans on HealthCare.gov, federal rules now set wait-time limits for appointments, like 15 business days for routine primary care and 30 for routine specialist visits. Many state-run marketplaces have their own rules.

♦ If you use an out-of-network provider, you may have to pay the full cost of the services you get from that provider if your plan doesn't cover out-of-network care.

The exception is emergency services.

♦ If you get emergency services from an out-of-network provider, those services are covered by a Marketplace plan as if you used an in-network provider. And since 2022, the provider can't balance bill you for the difference.

One big exception: ground ambulances aren't covered by the No Surprises Act, so an ambulance ride can still bring a surprise bill.

♦ For planned care, an out-of-network provider isn't obligated to accept what your plan decides to pay them.

The provider may try to bill you for the balance. This is called balance billing.

If this turns out to be a large sum, you should first appeal your insurance company's decision and try to get them to pay more.

• After the appeal is completed, if you still owe a lot, ask the provider to reduce the bill.

Most providers are willing to accept considerably less if they understand you can't afford to pay it all but can pay some.

Network Gap Exception

If you have a condition that requires treatment by a specialist, and your plan's network has no appropriate specialists, you may qualify for what's called a network gap exception.

Most health insurance plan documents don't actually say "network gap exception."

Your description of benefits might read: Coverage for services from non-participating providers requires prior approval.

♦ The rules for qualifying for an exception differ depending on the insurance company and the plan you have.

The horror stories about the many obstacles abound, but don't give up.

A network gap exception lets you see an out-of-network provider but pay the same as if you were seeing an in-network provider.

How to get a gap exception

You need to request a network gap exception from your insurance company.

♦ You must make this request before getting any services.

You can start the process, but often your primary care physician will make the request, because medical documentation will be needed, such as diagnosis and procedure codes.

Your insurer will determine:

• First, is the requested service covered by your plan?

• Second, is the service medically necessary?

• Third, is there a provider in your network who can provide the service you're requesting?

♦ Insurance companies fear higher costs if they approve a gap exception, because they don't have a contract with these providers.

At the same time, they're under some pressure from the Affordable Care Act to make sure their plans provide the coverage they promise.

Reasons for a gap exception

• There's no in-network specialist of the type you need within a certain distance. Your insurance plan sets that distance requirement.

• You're already on a treatment plan with a provider, and that provider suddenly leaves your network.

You ask for a gap exception to complete your treatments with the same provider.

The more specialized the treatments, the greater the chances of getting a gap exception.

Keep in mind the exception will be limited to the time needed to complete the treatments.

♦ Good news: since 2022, federal law gives some protection here. If you're being treated for a serious condition, are pregnant, have surgery scheduled, or have a terminal illness, and your doctor leaves your plan's network, you can generally keep seeing that doctor at in-network prices for up to 90 days. Your plan must tell you about this right.

• You're traveling and out of your network area. If it's not a true emergency, you need to call and request an exception for the services.

♦ Asking for a gap exception so you can keep your favorite doctor won't fly.

You and your doctor have to make a sound case for the exception.

If your request is denied, don't give up. You can appeal the decision, but first you need to find out why it was denied.

It may simply be because your doctor didn't provide all the information.