This section covers issues for those with coverage, including questions that may arise as they use their coverage.
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On Private Health Insurance Coverage & The Health Insurance Marketplace
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Post enrollment issues
FAQs +
- I was denied coverage for a service my doctor said I need. How can I appeal the decision?
- Does my health insurance plan cover abortion care?
- Does my health plan have to cover the cost of at-home COVID-19 tests?
- My insurer has denied coverage for my long-haul COVID treatment on the grounds it is “experimental” and not medically necessary. What can I do?
- My plan refuses to cover services related to gender transition. Is this allowed?
- I am taking pre-exposure prophylaxis (PrEP) to prevent HIV, but I received a bill for cost sharing for the labs I needed to start the medication. Is this allowed?
- I am taking pre-exposure prophylaxis (PrEP) to prevent HIV, but my insurance plan will not cover the medication my doctor prescribed without cost sharing. Is this allowed?
- My provider is asking me to give up my surprise billing protections in order to receive treatment. What should I do?
- I recently received a surprise medical bill from a doctor or hospital for services that should have been covered by my insurance. What do I do?
- What is a balance bill and how can I avoid it?
- My individual plan was retroactively cancelled even though I’ve been paying my premiums. I think it might be because I was recently diagnosed with a serious health condition. Is this allowed?
- My plan sent me a notice that they didn’t meet the medical loss ratio (MLR) standard. Will I get a rebate?
- I thought I was entitled to maternity coverage. Why isn’t it covered?
- I qualified for cost-sharing reduction subsidies when I signed up for coverage in the Marketplace. I’m getting more hours at work and might not qualify anymore. Will I have to change plans now and get a new deductible and out-of-pocket cap?
- What happens if I end up needing care from a doctor who isn’t in my plan’s network?
- I was in the hospital when my coverage changed from my old plan to my new, Marketplace plan. My provider during that episode of treatment is no longer in my plan’s network and I’m worried I’ll face higher cost-sharing as a result. Is this allowed?
- My doctor says I need a prescription drug, but it’s not in my health plan’s formulary. I didn’t realize that when I enrolled in the plan. Shouldn’t my plan be required to cover a drug that my doctor says I need?
- What should I do if my plan doesn’t adopt policies allowing patients to obtain prescription drugs not on its formulary, and I have to pay the full price of the drug?
- I pay more for my plan because I’m a smoker. If I stop smoking after I sign up, will my rates go down?
- Are annual physicals for adults and children available without cost-sharing as part of the preventive service requirements?
- I thought a colonoscopy screening was a free preventive service. When I went in for my screening, an abnormal growth or polyp was found and removed. I just received a bill for the removal of the growth. What can I do?
- I went for a preventive screening colonoscopy and received a bill for the anesthesia used during my procedure as well as for the pathology exam to examine the polyp that the doctor found. Is this allowed?
- I know recommended preventive services are updated all the time. Must my insurance cover newly recommended preventive services without cost sharing?
- I went to my doctor’s office for a flu shot, but was charged for an office visit. I thought preventive services were covered without co-pays. How can that be?
- There’s a co-pay for my brand name birth control pills, but not for the generic brand. I thought birth control bills had to be covered without any cost-sharing, is this allowed?
- I just found out that my provider is no longer in my network and I’ve been seeing him for years. What are my options?
- I have a lot of unexpected bills because of a natural disaster in my area, and can’t afford to pay my Marketplace premiums for the rest of the year. What are the consequences of not paying?
- One of the reasons I chose my health plan was because my prescription drugs are covered. Can my health plan make changes to what is covered once I’ve enrolled, and how will I know ahead of time?
- I have a $2,000 deductible but I don’t understand how it works. Can I not get any care covered until I meet that amount?
- I received a Form 1095-A called the “Health Insurance Marketplace Statement” in the mail. What is it and what do I do with it?
- What if there's a mistake on my Form 1095-A?
- What happens if my Marketplace insurer decides to discontinue its health plans on the Marketplace?
- There’s only one Marketplace insurer in my area. What happens if that insurer leaves the Marketplace?
- I evacuated from my area because of a natural disaster, and none of my doctors are close by. What are my options?
- I take prescription medication and got evacuated from my home because of a natural disaster in my area. I’m far from my local pharmacy and don’t know when I can get back. How can I get my medication?
FAQs +
- Does my health insurance plan cover abortion care?
- Does my health plan have to cover the cost of at-home COVID-19 tests?
- My insurer has denied coverage for my long-haul COVID treatment on the grounds it is “experimental” and not medically necessary. What can I do?
- My plan refuses to cover services related to gender transition. Is this allowed?
- I am taking pre-exposure prophylaxis (PrEP) to prevent HIV, but I received a bill for cost sharing for the labs I needed to start the medication. Is this allowed?
- I am taking pre-exposure prophylaxis (PrEP) to prevent HIV, but my insurance plan will not cover the medication my doctor prescribed without cost sharing. Is this allowed?
- My provider is asking me to give up my surprise billing protections in order to receive treatment. What should I do?
- My hours at work were cut back, resulting in a temporary loss of income. Can I qualify for premium tax credits?
- I recently received a surprise medical bill from a doctor or hospital for services that should have been covered by my insurance. What do I do?
- What is a balance bill and how can I avoid it?
- I got a letter saying my employer plan didn’t meet the medical loss ratio requirement (MLR). Will I get a rebate?
- I heard not all plans have to meet all rules. How do I know if my plan has to comply?
- My employer plan has an annual limit on my benefits. Is that still allowed?
- I thought there was an annual cap on my out-of-pocket costs, but I’m getting billed for something that puts me well above the limit. How can that be?
- My plan wants me to participate in a health risk assessment in order to get a discount on my premium. What are my rights?
- I had to complete a health risk assessment and now my employer is offering me a discount on my health insurance premiums if I will lose weight, stop smoking, and lower my blood pressure. What are my rights?
- My employer offers a smoking cessation program for smokers like me but I didn’t join it when I had the opportunity earlier this year, and now I have to pay more for my premiums. Can I join the program later and get my premiums decreased?
- When can I add family members to my employer plan?
- I’m losing my job-based coverage and have been given the option to sign up for COBRA. What are the pros and cons of doing that?
- I thought there was a cap on out-of-pocket costs but my prescription drug benefit requires me to pay co-pays even after I’ve met the out-of-pocket limit for other medical benefits. Is that allowed?
- I thought that contraceptives were now covered, but I heard on the news that some employers don’t have to cover them. Is that true?
- When I went to the pharmacy to get my birth control, I had a co-pay. I thought all contraceptive coverage had to be free?
- I need a hip replacement and when I asked my insurer about coverage, I was told that my plan uses reference pricing. What is that?
- I was denied coverage for my substance use treatment with my insurer saying it is not medically necessary. When I asked for the criteria to determine whether a treatment is medically necessary, I was told this information is proprietary. Is this allowed?
- I had coverage through my employer last year. The IRS tax filing instructions say my employer was supposed to provide me with a Form 1095-B or 1095-C. But I've never received either of those forms. What should I do?
- I thought prescription drugs were supposed to be covered in all plans, but my plan doesn’t include them. Is that allowed?
- I was denied coverage for a service my doctor said I need. How can I appeal the decision?