Health Insurance FAQ

No, you cannot be billed for out-of-network emergency care beyond your plan's in-network cost-sharing. The No Surprises Act (effective January 1, 2022) protects you from surprise medical bills for emergency services. You can only be charged your plan's in-network cost-sharing (copay, coinsurance, deductible), regardless of whether the emergency facility is in your network. If you receive a surprise bill for emergency services, tell the provider: "This is covered under the No Surprises Act. I should only owe my in-network cost-sharing amount."

You have the legal right to appeal any denied claim, and most denials can be overturned. First, read the denial letter carefully and note the deadline (usually 180 days). Gather evidence including medical records, a letter from your doctor explaining medical necessity, and relevant plan documents. Submit an internal appeal in writing, referencing the claim number and stating clearly why the denial is wrong. If the internal appeal is denied, you can request an external review by an independent reviewer - this decision is binding on the insurance company and free to you. Success rates are 40-60% of denied claims are overturned on appeal.

The No Surprises Act is a federal law effective January 1, 2022, that protects patients from surprise medical bills. It covers emergency services at any facility (in-network or out-of-network), ensuring you only pay your plan's in-network cost-sharing. It also protects you from balance billing when receiving care from an out-of-network provider at an in-network facility. Additionally, if you're uninsured or choose to pay out-of-pocket, you have the right to a Good Faith Estimate before receiving care.

A deductible is the amount you pay out-of-pocket before insurance starts sharing costs (example: $2,000 deductible means you pay the first $2,000). A copay is a fixed amount you pay for a specific service (example: $30 copay for a primary care visit). Coinsurance is your percentage share after meeting the deductible (example: 20% coinsurance means you pay 20%, plan pays 80%). All three count toward your out-of-pocket maximum - the most you'll pay for covered in-network services in a year.

HMO (Health Maintenance Organization) requires you to choose a primary care physician (PCP) and get referrals for specialists, but usually has the lowest premiums and copays. PPO (Preferred Provider Organization) allows you to see any provider without referrals, including out-of-network at higher cost, but has higher premiums. EPO (Exclusive Provider Organization) combines features of both - no referrals needed but only in-network coverage (except emergencies), with moderate premiums.

An EOB shows what happened when your insurance processed a claim. Key sections include: 1) Service details (date, provider, procedure codes), 2) Billed amount (what the provider charged), 3) Allowed amount (what your plan agreed to pay), 4) Plan paid (insurance portion), and 5) What you owe (your copay, deductible, or coinsurance). Always compare your EOB with any bills you receive - if there's a discrepancy, call your insurance company. The EOB is not a bill itself.

The SBC is a standardized document that all health plans must provide, summarizing key features like covered services, cost-sharing, and limitations. It includes important details like your deductible, out-of-pocket maximum, and what you pay for common services. The SBC uses uniform formatting and language to help you compare plans. It also includes coverage examples showing how the plan would handle common medical scenarios like having a baby or managing diabetes.

HIPAA gives you important rights over your health information. You have the right to: see and get copies of your medical records, request corrections to your records, receive a notice of privacy practices explaining how your information is used, request restrictions on who can see your information, choose how you receive health information, and file a complaint if you believe your privacy rights have been violated. Healthcare providers can share your information for treatment, payment, and healthcare operations without your permission.

Prior authorization is approval from your insurance company before you receive certain medical services, procedures, or medications. It's designed to ensure medical necessity and control costs. Common services requiring prior auth include specialty medications, certain surgeries, medical equipment, and some diagnostic tests. Emergency services cannot require prior authorization. If your doctor recommends a service needing prior auth, they typically handle the request, but you should follow up to ensure approval before receiving care to avoid unexpected costs.

No, under the Affordable Care Act (ACA), health insurers cannot deny coverage or charge higher premiums based on pre-existing conditions. This applies to any health problem you had before your coverage started - including pregnancy, diabetes, cancer history, mental health conditions, or any other medical condition. This protection applies to all individual and group health plans, but not to short-term health insurance plans, which can still exclude pre-existing conditions.

COBRA allows you to continue your employer's health insurance after leaving your job, but you pay the full premium plus up to 2% administrative fee. You get 18 months of coverage (36 months in certain situations like divorce or death). You have only 60 days from losing coverage to elect COBRA - miss this deadline and you lose the option permanently. While expensive (often $1,500-2,000/month), COBRA can bridge coverage gaps and is often better than marketplace plans if you have ongoing medical needs.

Under the No Surprises Act, if you're uninsured or choose to pay out-of-pocket, you have the right to a Good Faith Estimate before receiving care. The estimate must include expected charges for the service and any other providers involved (like anesthesiologists or lab services). Ask your provider: "I'd like a Good Faith Estimate for this service under the No Surprises Act." You should receive it within 3 business days for scheduled services or 1 day for services within 72 hours. If your actual bill exceeds the estimate by $400 or more, you can dispute it.

Balance billing occurs when a provider bills you for the difference between their charge and what your insurance pays. For example, if a doctor charges $200 but your insurance only pays $120, balance billing would charge you the $80 difference (plus any copay/deductible). The No Surprises Act protects you from balance billing in emergency situations and when receiving care from out-of-network providers at in-network facilities. However, balance billing may still occur for non-emergency care when you knowingly choose an out-of-network provider.

Yes, under the Mental Health Parity and Addiction Equity Act (MHPAEA), health plans must cover mental health and substance use disorder benefits at the same level as medical/surgical benefits. This means if your medical specialist copay is $40, your mental health specialist copay cannot be higher. Plans cannot have separate, higher deductibles for mental health or more restrictive prior authorization requirements. Coverage must include outpatient therapy, inpatient mental health treatment, and prescription medications for mental health conditions.

A special enrollment period (SEP) allows you to enroll in or change health insurance outside the annual open enrollment period when you experience certain qualifying life events. Common qualifying events include getting married, having a baby, losing job-based coverage, moving to a new area, or losing Medicaid/CHIP eligibility. You typically have 60 days from the qualifying event to enroll. Unlike open enrollment, you must provide documentation proving your qualifying event to access a special enrollment period.

After your insurance company denies your internal appeal, you can request an external review by an independent organization. You typically have 4 months to request this review. The external review is conducted by independent medical experts who evaluate whether your treatment should be covered based on medical necessity and your plan's terms. The decision is binding on your insurance company, meaning they must follow the reviewer's decision. External review is free to you and available for most types of coverage denials.

Under the Affordable Care Act, certain preventive services must be covered at no cost when provided by an in-network provider - no copay, coinsurance, or deductible. These include annual wellness visits, immunizations, cancer screenings (mammograms, colonoscopies, pap smears), blood pressure and cholesterol checks, depression screening, and contraceptive services for women. The specific services depend on your age, gender, and risk factors. These services are only free when provided by in-network providers and for preventive purposes (not diagnostic).

Coordination of benefits determines which insurance plan pays first when you're covered by multiple health plans (like through your employer and your spouse's employer). The primary plan pays first according to its benefits, then the secondary plan may pay some or all of the remaining costs. Rules determine which plan is primary - typically your own employer plan is primary over your spouse's plan. The total benefits from both plans cannot exceed 100% of the allowed charges, and having dual coverage doesn't guarantee all costs will be covered.

Whether you can keep your doctor depends on whether they're in your new plan's network. In-network providers have contracted with your insurance company to provide services at negotiated rates. If your doctor is out-of-network, you may still be able to see them, but you'll typically pay much more out-of-pocket. Before switching plans, check the plan's provider directory to see if your preferred doctors and hospitals are included. You can also ask your doctor's office which insurance plans they accept.

First, determine if the No Surprises Act applies - it covers emergency services and situations where you receive care from out-of-network providers at in-network facilities. Contact the provider and state: "I believe this bill violates the No Surprises Act. I should only owe my in-network cost-sharing amount." Request they reprocess the claim under No Surprises Act protections. If unresolved, file a complaint at cms.gov/nosurprises or call 1-800-985-3059. Also contact your insurance company to ensure they processed the claim correctly under the new law.