If you’re newly enrolled in an Affordable Care Act (ACA) plan – either through your employer or an individual major medical policy – or you just want a refresher on tips for using your coverage, keep reading. You’ll learn more about:
- How to understand and use your coverage to help improve your health and protect your finances
- What to do about coverage gaps that could potentially leave you underinsured (meaning that paying for your out-of-pocket medical costs could consume a significant portion of your household income)
If you’re among the 23% of Americans who find themselves underinsured[2], supplemental health insurance may be available to help cover your out-of-pocket medical costs, such as deductibles and coinsurance.
And don’t forget about dental insurance. Oral health plays an important role in your overall health[3] , and a dental policy can help pay for the regular checkups and cleanings recommended by dental professionals.
1. Get to Know Your Health Insurance Plan
Look through your membership materials. You’ll want to be familiar with your plan basics such as your deductible, copay and coinsurance amounts.
This is also a good time to review your policy to understand if it pays different benefits for in-network versus out-of-network care, and whether or not you’ll need to contact your health insurance carrier for preauthorization of certain medical care, or for a referral for a specialist.
Keep your health insurance card in your wallet so you can show it to your provider at your next appointment. The card contains important plan details and call center information that your provider’s office needs when filing an insurance claim after providing you care.
Many health insurance companies give you the ability to conveniently manage medical appointments, communicate with them securely, view health records and pay your monthly premium online. Information about creating or logging in to your account is usually included with your welcome packet. Familiarize yourself with your account and what materials the insurance company makes available online.
2. Choose In-Network Providers
Not all healthcare providers take all health insurance plans. Contact your insurance carrier to verify that your favorite doctor, usual pharmacy, and preferred urgent care center and hospital system are covered by your health insurance plan and considered in-network.
If you don’t have a preferred set of providers, take some time to check your insurance carrier’s network and learn about in-network providers near you who are accepting new patients. These tips can guide you on how to find a primary care physician.
Your health insurance plan’s online provider directory contains a list of in-network doctors and clinics; however, when scheduling your appointment, ask if the provider still accepts your health insurance. Online directories can sometimes be out of date.
Want to learn more about networks? Find out about narrow networks, or learn about the difference between HMO, PPO, EPO and POS managed care plans.
3. Know What to do in Case of a Minor Injury or Illness
Check your provider directory to locate your nearest in-network urgent care or in-store clinic. Research their hours of operation and your copay for these visits, so you’re prepared for any minor medical emergencies.
Another cost-effective way of accessing healthcare is to ask your insurance carrier if your plan covers “virtual care visits.” Growing in popularity[4] , virtual care visits can be less costly and more convenient than traditional office visits for treating minor problems like colds/flu, skin rashes, pink eye, and sinus infections.
If your insurance plan does not include virtual healthcare services, you can purchase telemedicine services separately. (Telemedicine is not insurance.)
Remember, in a true emergency, call 911 and obtain emergency services. Insurers cannot require that you get prior approval before obtaining emergency room services. You also cannot be required to pay higher copayments or coinsurance for getting emergency care from an out-of-network hospital.[5]
Want access to virtual health care from home?
4. Be Proactive About Prescription Drugs
If you’ve already checked that your current pharmacy is in your network, or selected a new in-network pharmacy, great! If not, take a few minutes to call your insurance company or check their website for a list of participating providers.
Your next step is to confirm that any regular prescriptions you take are part of the drug formulary covered by your insurer. You don’t want to run out of a prescription and find that it’s not covered by your new plan.
What can you do if your medication is not covered? Ask your insurance company:[6]
- If you’ll receive coverage for a one-time refill until you can speak with your doctor about a different prescription
- To provide you details about your insurer’s drug exceptions process, which enables you to get a prescription medication not normally covered by your plan.
Should your insurance company continue to deny coverage for your prescription medication, you may file an external appeal and have your case reviewed by an independent third party.[7]
A prescription drug discount program may also be able to help make prescription drugs more affordable if your current pharmacy or prescription is not covered by your insurance. However, it’s important to note that these programs are not insurance and cannot be used in conjunction with your insurance benefits.
5. Prepare for Office Visits
After you’ve located an in-network provider and scheduled an appointment, make sure you’re prepared for your visit. It may be a good idea to bring any information you maintain about your health history or a copy of your medical records if you have it. This may make it easier to discuss any specific health concerns, and providing relevant medical records information to a new provider can help ensure you get a more effective diagnostics and treatment plan. Learn more about how to create a personal health record.
Be sure to bring your insurance ID card with you to your appointment. When you check in at the clinic or hospital, you will be asked to show your card as proof of insurance.
If your plan has an office visit copayment, you may also be asked to pay that amount. Your insurance card may list your office visit copay, but if you have any questions, contact your carrier’s customer service number or check your membership materials, to avoid any billing surprises when you arrive for your appointment.
6. Take Advantage of Preventive Services Covered by Your Plan
The Affordable Care Act requires all major medical insurance plans to provide 10 essential health benefits which include certain preventive care services, such as shots and screening tests.
When you receive these services from a provider in your insurance plan’s network, they are provided at no cost to you.[8] That means you will not be charged a copay or coinsurance for these services, even if you have not yet reached your plan’s deductible if this is the sole purpose for your visit.[9]
These services vary by age and gender, and include vaccinations and screenings for:
Adults — such as blood pressure, cholesterol and cancer screenings, as well as counseling for chronic conditions such as diabetes, and much more.[10]
Women — including pregnancy-related screenings and condition counseling, well-woman visits, tobacco use and screening and interventions, and many other services.[11]
Children — such as behavioral assessments, developmental and depression screenings, immunizations, testing for environmental risks such as lead screening, and much more.[12]
Preventive care is designed to help you maintain health by identifying illnesses and conditions earlier, which may help you and your doctor manage and treat them more effectively.[13]
Learn more about your ACA plan’s preventive care coverage.
Dental checkups are good preventive care measures, too.
Under the Affordable Care Act, dental coverage is considered an essential health benefit for children 18 and younger, and must be offered by all ACA-compliant plans.[14] Oral health is just as important for adults. Brushing, flossing and regular dental checkups have been shown to protect your overall health.[15]
If your major medical plan offers you the option to add dental coverage, that’s one way you can receive low- to no-cost dental checkups each year to keep your oral health at its best.
Otherwise, you may find private dental insurance to be an affordable option for maintaining your bright smile. Learn more about dental insurance for the whole family.
7. Use Any Discounts and Programs
Some insurance companies include health and wellness programs along with their insurance coverage,[16] such as premium discounts, gym memberships, cash rewards, apps to track prescriptions and health records, and more. Check your insurance company’s website for details on programs and incentives. These are generally not insurance products.
Complement your insurance coverage with discounts for alternative therapeutic treatments
While more individuals are engaging in holistic healthcare and wellness practices, such as acupuncture, chiropractic care, therapeutic massage, yoga and more,[17] traditional health insurance plans don’t always pay benefits for these types of services.
A health and wellness discount plan – which is not insurance – can provide you discounts for integrative medical practices to complement the standard healthcare services covered by your major medical insurance.
Get discounts for therapeutic massage, acupuncture, and more.
Enroll in Health + Medical Discounts
8. Consider Ways to Manage Your Deductible
With the exception of preventive care services, health insurance benefits typically will not be paid under your insurance plan until you have met your deductible. That means you are responsible for paying your healthcare costs out of pocket up to that point.
This is where some people could encounter affordability issues with their major medical policies and may even find that they are underinsured…
Once you fulfill the deductible, you will be responsible for a percentage of covered medical care until you reach your policy’s annual out-of-pocket maximum. Your plan then will cover all of your eligible healthcare expenses for the remainder of the year at 100%.
In 2021, the out-of-pocket maximum for an individual ACA-compliant plan is $8,550 and $17,100 for a family.[18]
If you have questions about deductibles, you can read more about how health insurance deductibles work. If you’re wondering how to address a coverage gap if you have higher out-of-pocket costs, supplemental coverage may be an option.
Supplemental coverage for high deductible plans
If you select a health plan with a higher deductible you may have lower monthly premiums. However, it may be more challenging to cover all of your out-of-pocket costs not covered by your major medical insurance plan.
A medical gap insurance plan may provide lump sum benefits when you experience a covered accident or illness. This type of supplemental policy is designed to help pay for out-of-pocket expenses, including deductibles, copays or coinsurance, but you can use the lump sum payments towards any expenses you choose.
Medical gap insurance is not ACA-compliant coverage and does not cover pre-existing conditions. Premiums for medical gap coverage are calculated using factors such as your age, health status and chosen benefits.
You can apply for a medical gap policy at any time. It’s easy to get a quote and find out if this so-called “insurance for your insurance” can help provide you financial protection from costly out-of-pocket medical expenses.
Compare medical gap coverage and costs.
9. Pay Medical Bills on Time, Ask Questions and Get Assistance if You Need it
After you receive medical care, you will get an Explanation of Benefits in the mail. This document is not a bill. It simply explains what services you received, how you were charged, and what portion your health insurance benefits covered.
You will receive a bill separately. Before you pay, call your health insurance carrier if you need clarification about the billing process or are concerned about billing errors. If you’re experiencing a complicated medical situation with significant and expensive care, an independent medical billing advocate may be able to audit your medical bills and even negotiate lower costs for your care.[19]
Find more tips on negotiating, disputing and preventing surprise medical bills.
10. Fill in the Gaps
Now that you’re equipped with several ways to make the most of your major medical insurance, take a few moments to assess if there are any gaps in your coverage. There are more Americans today than ever before who find it challenging to pay their medical bills, or decide to skip healthcare, because their out-of-pocket costs are too high compared to their income.[20]
Supplemental health insurance, dental coverage and even a non-insurance health and wellness discount plan can help you access the care you need at a more affordable cost.
Get help with your oral health with dental insurance.
Summary + Next Steps
ACA Major medical insurance can help by paying a portion of your covered medical expenses and helping you access no-cost preventive care. Taking advantage of your plan’s benefits can also help you maintain good health, or more effectively manage a chronic condition.
If you’re concerned that it may be difficult for you to cover your out-of-pocket expenses when you use your health insurance, consider a medical gap plan. This type of supplemental, non-ACA-compliant plan is designed to provide you lump sum benefits when you experience covered illnesses or accidents.
For more details about medical gap coverage or dental insurance, call (888) 855-6837 to speak to a licensed agent that can help you understand your options.
