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CREDIT: Get Covered America

Nina Perez's picture

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You’re insured—YAY! Now it’s time to access your coverage. Using new coverage for the first time can be daunting—but don’t worry! Here’s a list of 10 things to know about using your health coverage.

1. What does my new ACA health insurance cover?

If you recently purchased insurance on your state or federal marketplace, you can expect your new health insurance to cover in-network doctor visits, hospitalizations, prescriptions (there may be coverage level variations based on prescription type), maternity care, infant care, mental health, and additional preventative care services. These are part of the 10 essential health benefits now covered because of the new healthcare law.

2. What does mean when the insurance company says I need to find a provider?

The provider is the medical professional that will be delivering your medical care.  It might be your doctor, but it can also be a nurse, dentist, midwife, and other health care specialists. 

3. How do I find out what doctors are covered under my new plan?

Visit the insurance carrier website to find the provider directory or call to get the information over the phone. But, to absolutely confirm that your provider is covered, it’s a good idea to call your provider’s office directly and ask them if they are covered under your plan. Make sure to have your insurance card ready and available when you check-in with the provider.

4. What do I bring to my first doctors visit?

Before visiting the doctor, you may want to reference the “Roadmap to Better Care and a Healthier You” toolkit for general tips and suggestions. Top items to remember though are your Insurance card (and relevant paperwork), Photo ID, your copayment if needed (see #5 for copay explained), and pertinent health information (like medications you are currently taking).

5. My provider said I had to pay a “copay.” What is a copay?

Your copayment is a set amount of money you may be asked to pay your for a medical service—like a doctors visit or prescription.  This amount is established by your insurance company and varies based on your coverage level (bronze, gold, silver, and platinum). To find out more about your copay, you can review your Benefits Summary or Evidence of Coverage. If you have trouble finding the information there, you may want to call your insurance company to get the information.

6. What if I don’t like my primary doctor? Can I change providers?

Yes, you can change to another in-network provider if you feel like you aren’t getting quality of care or feel uncomfortable with your provider. It’s important to feel comfortable with your doctor, so don’t be afraid to switch.

7. Does my new coverage cover emergency hospital visit expenses?

Trips to the emergency room are one of the 10 essential health benefits and are covered, but you may have some other out of pocket costs based on your plan or the hospital. But, as discussed on healthcare.gov, your insurance coverage “can’t make you pay more in copayments or coinsurance if you get emergency care from an out-of-network hospital.”

8. How do I find out if my new plan covers a prescription I need?

You should review the “Summary of Benefits and Coverage” your insurer sends you for your plan. If it’s still unclear, you should call the insurer directly to see what prescriptions are covered. If your prescription is only partially covered or not covered at all, you can go through the exemptions process with your insurance company.

9. Who do I pay my first monthly premium payment to—the marketplace of the insurance company?

You won’t receive your insurance card until you’ve paid your first monthly premium—which you pay directly to your insurance provider.  If you haven’t been able to pay the premium yet, call your insurance company to check your status.

10. What if I think something is supposed to be covered, but the insurance company is saying it isn’t?

In this case, you should attempt to appeal the decision as discussed on healthcare.gov: “Your insurance company must first notify you in writing within a set amount of time (based on the type of claim you filed) to explain why they denied coverage. They also must let you know how you can appeal their decisions.”

If you have other questions or concerns, don’t hesitate to reach out to us at healthbeat@momsrising.org or visit healthcare.gov.


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