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My Employer Does Not Offer Coverage- How Can I Buy Health Insurance For My Family?

It’s important to know that in the coming months, certain employers will be required to provide health insurance to their employees. This is applicable beginning in January of 2015 for employers with 50 or more full time equivalent workers. If the business foregoes providing healthcare coverage, the company is subjected to a tax penalty. This is most often discussed using the term employer mandate.

Many other employers who are not affected by a tax penalty might decide that it’s better to avoid providing that coverage altogether because of the high cost of healthcare. They might try alternatives like a defined benefit plan, but this doesn’t really help you if you are looking for health insurance for you and your family. You may need to seek your own plan through a health insurance exchange.

Beginning in January 2014, it was mandatory for most individuals to obtain health insurance coverage or be subjected to a tax penalty. Over time, the penalties become more severe. There are people who are exempted from this penalty, but the majority of the people shopping on the healthcare exchanges are simply interested in finding an affordable and quality option for their families.

If you have not been able to get covered under your employer, it’s time to look at the health insurance exchange. While enrollment periods for 2014 have already passed (unless you meet the qualifications for a special exemption that allows you to enroll outside of this period), you can begin considering options for 2015 in November.

The health insurance exchanges are sponsored by each state with the overarching goal of providing a one-stop shop for all of your healthcare needs. Easily logging on to a website gives you full access to a range of plans that suit your needs. With prohibition of denials for coverage based on pre-existing conditions and required stipulations regarding what kinds of services must be covered in a plan, you’ll have much less to worry about when seeking your coverage through a health insurance exchange.

The exchange breaks it down so that you can see exactly what you’re getting in terms of cost, deductible, and plan benefits. For many people, they find that purchasing coverage outside of the employer gives them the option to select the most appropriate plan for their own needs in a convenient manner.

My pharmacy is not taking my insurance from Covered California- What Can I Do?

Just as many healthcare plans provide options for different medications, health plans also allow for you to get your medicines from pharmacies known as “in network” pharmacies. You’ll want to contact your insurance company or take a look at their website to determine if the pharmacy you work with takes your new plan. If you find out that it’s not covered with the pharmacy you already work with, you may be able to see on the internet what other pharmacies do cover the plan that you have.

As an alternative, you may be able to receive your medications through the mail. Doing your research and finding out what you are eligible for is likely to ease a lot of your fears. If your health insurance company won’t cover your prescription, you may also pursue your right to appeal that decision and have the case reviewed by a neutral third party.

To learn details about what prescriptions are covered and what pharmacies are considered in-network, visit the insurer’s website to determine the list of prescriptions that are included with your plan, verify your coverage and benefits summary, contact the insurer directly, or review the hard copy materials you received.

If you get to your pharmacy and are told that your plan no longer covers it, some insurers may be willing to allow you a one-time refill after you initially enroll in the plan. This is to give you some time to determine the next best step by meeting with your doctor. You can also initiate the insurer’s drug exception process, but you need to discuss this directly with a plan representative as their rules can vary.

For the most part, your doctor will have to confirm to your health plan representatives that the drug is appropriate for your medical condition based on a few factors, such as there being a limit on the number of doses you’re allowed, whether an alternative drug that is covered by your plan is likely to give you side effects that could be harmful or dangerous to you, or whether other drugs that are covered by your health insurance plan are not as likely to be as effective as the drug which you are presently taking.

As you can see, there are multiple options to take if your medication or pharmacy is no longer included in your plan.

I Don’t Understand the Difference between an HMO Plan and a PPO Plan

When you’re selecting new healthcare coverage, it’s very important to be sure that you are looking at all the right details and comprehending the differences between the various services. One of the most common questions surrounding this is with regard to the differences between an HMO and a PPO Plan. Educating yourself about what you get with each type of plan will allow you to make an informed decision.

The first major difference between these two plans is simply to do with price, but that is linked to the features and benefits included in the plans as well. The most common types of plans are HMO plans, which are named for Health Maintenance Organizations. Less common, but more expensive plans are known as PPOs, or preferred provider organizations.

Every healthcare plan that you select is going to include contracts with clinics, hospitals, doctors, and healthcare providers that are considered part of a “network” In managed care plans through HMOs, it’s very likely that you will need to receive all of your care from providers in the network, otherwise you might find out that you are being charged for visiting a physician outside of your plan, for example. While there are some cases you might choose to do this, not realizing the implications of going outside of network can be extremely expensive when you’re presented with the final bill that insurance will not cover.

In the HMO plan, you will select a primary care physician who will provide all of your basic and general healthcare services. If you need to visit a specialist, you will have to get a referral from this individual.  If you don’t get the referral or see someone outside of the network, you’ll likely be footing the bill for those services.

In a PPO plan, the contracts are with a network of preferred providers. You are not required to select a primary care physician, and you won’t need those referrals to other providers in the network for specialized care. If you get care from a doctor in the preferred network, you are only responsible for your deductible and a copay for your visit. If you opt for doctors outside of the preferred network, you will have to pay a higher amount and you may need to pay the doctor directly and get reimbursed after from your insurance company.

What is a State Health Insurance Exchange?

State health insurance exchanges are part of the Affordable Care Act rollout. States either implemented their own state run health exchange or they have opted to let the federal government create the exchange for them. Some states have also partnered with other states or the federal government to create a hybrid type of exchange. Your health insurance exchange might also be called a health insurance marketplace.

There is a lot of flexibility in the Affordable Care Act that gives individual states options for how to run their exchange. As a result, many states who have taken it upon themselves to craft an exchange have opted to find the best way to present insurance options to residents of the state. In this sense, you can see how the health insurance exchange is like an online market. You can shop for plans, compare plans against one another, and learn more about the implementation of healthcare reform.

The goals of health insurance marketplaces are to provide you with options and empower your decision making. The purpose of having them online is that it makes it easier for you to read through all the coverage options. In the past, insurance has been difficult to purchase because of the variety of fine print and challenges in understanding all the small nuances of a policy. Hoping to eliminate some of those problems, which led people to forego insurance entirely or to select a plan that did not really meet their most critical needs, state insurance exchanges try to present information in a clear and helpful manner.

On your state’s health insurance exchange, you can review all the plans that fit your application. All plans are required to provide some basic services, but you’ll want to ensure that you have found a plan that best suits your needs when it comes to premium costs, co-pays, and deductibles. You might have to do some shopping around to identify the best plan for you and your family, but the health insurance exchange makes that easier. You can clearly see what sets one plan apart from another, giving you the opportunity to narrow down your choices to a handful of plans. If you need more help or information, it’s available, but many people have been able to research and select the best plan for them simply by going online. New enrollment for 2015 opens in November- have you gotten coverage yet?

Whats Cheaper? Buying plans on my own or buying COBRA Insurance.

If you have been laid off or fired from your job, the amount of details you may be considering can be overwhelming. It can be difficult to figure out where to start, but health insurance should certainly be something you consider fixing right away. Typically, you’ll expire out of your employer sponsored coverage at the end of the month or billing period for that coverage.

Your employer is legally obligated to give you the option of continuing on with your existing plan at your own cost for up to 18 months after you leave your job. Shortly after leaving, you should receive sign-up details from your employer to learn more about what you’ll need to do if you plan to keep your existing coverage. On the plus side, COBRA can allow you to continue your coverage as you search for a new job or other options. On the downside, however, your coverage is likely to be extremely expensive.

Many people who are laid off or are fired find that the high cost of COBRA is not something they can afford being newly unemployed. Unless you have banked significant savings and are concerned about emergency care or services for an existing condition, COBRA may not really be an option for you. In addition to fronting the cost for your own care and your family’s care, your employer has the option to add on a 2% administration fee for continuing to manage the plan. Overall, the cost of keeping your coverage through COBRA can be far too much to make it worth it.

Thankfully, you do have another option, and that is getting coverage through the health insurance marketplace. Although enrollment periods for signing up in general are limited each year, being laid off from your job means that you could qualify for a special enrollment period for up to 60 days after your termination from your employer. You’ll need to provide all the information for your coverage, as well as your income level, in order to see what plans are available. Make sure you act sooner rather than later if you are concerned about a lapse in coverage causing serious problems for you or your family.

While it’s hard to return to normal life after being laid off, you need to act quickly to determine how you will be maintaining health insurance coverage.

What’s the difference between deductible, Copy and coinsurance?

Learning about the terminology related to health insurance can be very confusing, especially since it’s so important to understanding the benefits that you have and what you will be responsible for under your health plan. Without realizing what you are entitled to and what you have to come up with on your own, you could be facing an unpleasant surprise after visiting the doctor or getting a procedure done. This article is intended to help you answer one of the most common questions about deductibles, copays, and coinsurance.

It’s vital that you be aware of this if you already have health insurance, but it’s even more important to be informed if you are in the market for new insurance. These are  the finer details that can help you identify the plan you really need. With the launch of the healthcare reform known as the Affordable Care Act, it’s more important than ever that you educate yourself.

One of the most common terms related to your health insurance coverage is your premium. This refers to what you pay each month for the privilege of having healthcare coverage. Another important term is deductible, and this is usually one of the first numbers you will encounter. This is considered the amount that you must kick in first for your healthcare costs, before your insurance company will step in to pay their portion. Choosing a healthcare plan with a high deductible may not be worth it if you don’t hit that deductible to allow the benefits to kick in.

A co-pay and co-insurance are different than a deductible. These refer to deductible as well, so you can see why it’s so important to shop around and identify the right mix of deductible and premium as well. A co-pay is the routine cost for services you’ll need to pay at each doctor’s visit, for example. This is an amount for which your deductible does not apply, so bear in mind that your co-pays are not building you up to that deductible “cap” where the health insurance company kicks in. Your coinsurance, on the other hand, refers to the percentage that you will be responsible for after the deductible has kicked in. For major procedures, for example, you’ll likely be responsible for some portion of the treatment, and you’ll want to read the fine print in your insurance policy to determine this.

I have insurance through my employer- how will Obamacare affect that?

If you already have insurance through your employer that you like, you can keep it. If your employer doesn’t offer health insurance coverage that meets the minimum coverage standards, though, or if you do not have health insurance options through work at all, you can search for an appropriate plan on the health insurance exchange.

At the passage of the Affordable Care Act, the majority of people who already had coverage under an employer are eligible to keep it because those policies were grandfathered in. The reasoning behind this choice is that while there were many Americans who did not have access to quality plans prior to the implementation of the Affordable Care Act, it was recognized that there were also many individuals who currently had healthcare plans and employer options that they did like. There is no reason to change if you are still obtaining coverage under a plan that you like.

Since there have been so many changes in the marketplace, though, make sure you review your plan options through your employer. Many employers have opted to make changes in the provider or in the types of plans offered, so it’s always in your best interest to review those materials on a regular basis so that you are clear about the value and the mechanics of the plan.

If you do not have coverage through an employer-sponsored plan because you are not eligible for one, because you recently became unemployed, or through some other special circumstance, you may be eligible for coverage through the state health insurance exchanges. Note that outside of regular enrollment periods, you must meet an exception to qualify for coverage.

For the most part, if you have employer-offered coverage, you are considered covered. You could be eligible to switch over to Marketplace coverage, but you will lose out on the employer contributing towards your health plan. In many workplaces, your employers helps to subsidize the cost of your premiums. Switching over the marketplace coverage will mean that you might not qualify for lower premium costs due to your income. This all depends on the kind of coverage your employer offers, but if the plan is grandfathered in, it’s considered to be minimum essential coverage and you might not save anything by switching to the marketplace. You’ll lose out on premium savings that you could have met if you did not have the employer based coverage.

What if My Doctor is not taking my Covered CA Plan? What Are My Options?

Unfortunately, you may learn after opting in to a Covered California plan that your doctor no longer accepts that plan. Some individuals in California have faced this situation as a result of technical glitches, wherein their doctor was listed on the website detailing coverage details but wasn’t actually accepting the plan.

In those cases, you may be referred to a customer service representative to help you identify another in-network doctor to perform the procedures or services needed. Part of the reason that some providers are not accepting certain plans is because of the opportunities offered by Covered California. Since the health insurance exchange has added more competition into the market,insurance companies have had to go back to the drawing board to find effective ways to remain competitive themselves. In many situations, this results in controlling plan costs by limiting networks of providers. In fact, this trend is now new, but has simply been accelerated by the competitive nature of the Covered California exchange.

Another associated challenge is that doctors often move from one group to another or become affiliated with a bigger group, making it difficult to track down through a database whether a provider is actually accepting that insurance or not. Although doctors are often required to update the insurance company if they have moved to another group, that protocol is not always followed.

If you discover that your doctor is not accepting a Covered California plan, you may have to do some research on your own, especially if you are aiming to get covered for a specific medical need like a procedure. Although the online networks that identify providers might be a good starting point, they are not always entirely accurate, which is why you should spend some time making phone calls to identify other providers in your area that do accept your coverage. Remember that more than 80 percent of California doctors are actually included in the state healthcare exchange plans and a majority of state hospitals are included in the plans, but you may want to do some your own research and verification. Getting details in writing may also be helpful if you want to ensure that you are using your plan to the fullest. If you discover that the doctor you have been seeing is not in the network, contact your insurance provider to identify someone else.

Why is Kaiser Different From Other Providers?

If you are looking at your coverage options for healthcare for the next year, you might be considering Kaiser Permanente as an option. Compared to other providers on the California health insurance exchange, and depending on your exact location, Kaiser might be showing up as one of the more expensive healthcare options both for individuals and families.

While Kaiser offers plans with many of the same benefits as other California plan providers, they are a different type of company. This is because they are considered “truly integrated” with their own healthcare delivery system both in the state and around the country. They have their own clinics, hospitals, other essential plan components, and even their own healthcare professionals within their system. While for some this could be viewed as a professionalization and a standardization across their various forms of care, it can also make things more expensive. Another benefit of being structured like this is that the company is essentially able to provide all services to each of their plan members because of this extensive system.

The downside of that is that it can be expensive to maintain such a system, even when it has bene streamlined. Careful execution of a strategy like this and advance planning are critical for the company to get the most out of this but also for insured individuals to capitalize on the strengths of their plan. Plans like this are dependent on big enrollment, because the cost of enrollment, when spread out over so many individuals, can help to keep the costs reasonable and therefore present a sensible perspective on keeping so many facilities and providers managed under the Kaiser Permanent system. It’s a delicate balance, because sudden surges in patients and enrollment could even put a strain on such a system, but too low enrollment means that it doesn’t really pay off to have such a big system built in.

It’s important to know that there are many different plan options under Covered California and that the purpose of a health insurance exchange is to give you plenty of choices to determine the best fit for you and your family. One of the advantages of selecting a plan through Kaiser is that you’ll benefit from the standards and system already developed in-house. For some families, that could be a perfect fit. Remember that you can use the health insurance exchange to shop around.