Navigator Guide FAQs of the Week: Answers to Post-Enrollment Questions

Open enrollment has officially ended in most states. Thanks to this year’s extended open enrollment window, the majority marketplace-eligible individuals and families had an extra month to select a plan. CMS announced a record number of consumers had signed up for 2022 marketplace coverage a few days ahead of the January 15th enrollment deadline for HealthCare.gov. So what comes next for marketplace enrollees? After taking steps to finalize and stay enrolled in your health plan, give yourself a pat on the back! Second, consult CHIR’s Navigator Resource Guide for expert answers to FAQs about post-enrollment issues you may face, like unexpected coverage denials and balance bills.

I was denied coverage for a service my doctor said I need. How can I appeal the decision?

If your plan complies with the Affordable Care Act and it denied you coverage for a service your doctor said you need, you can appeal the decision and ask the plan to reconsider their denial. This is known as an internal appeal. If the plan still denies you coverage for the service and it is not a grandfathered plan, you can take your appeal to an independent third party to review the plan’s decision. This is known as an external review.

You will have 6 months from the time you received notice that your claim was denied to file an internal appeal. The Explanation of Benefits you get from your plan must provide you with information on how to file an internal appeal and request an external review. Your state may have a program specifically to help with appeals. Ask your Department of Insurance if there is one in your state.

For more information about the appeals process, including how quickly you can expect a decision from your plan when you file an internal appeal, click here.

What is a balance bill and how can I avoid it?

“Balance bills,” often referred to as surprise medical bills, can occur in two circumstances that can come as a surprise to patients:

1) When you receive emergency care either at an out-of-network facility or from an out-of-network provider, including air ambulances; or

2) When you receive elective nonemergency care at an in-network facility but receive services during your visit or procedure from an out-of-network health care provider, such as an anesthesiologist, radiologist, hospitalist, or other physician.

Since the insurer does not have a contract with the out-of-network facility or provider, it may cover only a portion – or none – of the bill. In that case, the out-of-network facility or provider may then bill you for the remaining balance of the bill. These bills can be high and are often unexpected, particularly when you have made every effort to get your care at an in-network facility.

A new federal law that takes effect in 2022 protects patients from receiving these surprise balance bills, ensuring they only have to pay for in-network cost sharing in the two situations described above (notably, the federal law does not apply to ground ambulances). Many states have also enacted their own laws to protect enrollees in certain types of health plans, but the new federal laws will act as the minimum level of protection in all states (meaning states cannot set different rules that provide less protection than the new federal law, but your state may have higher standards – check with your state Department of Insurance to understand your rights).

While the new federal law protects you from paying more than in-network cost sharing in the abovementioned situations, in rare cases, patients may choose to get non-emergency care out of network. In such a circumstance, subject to requirements and limitations, patients may waive their protections. However, patients cannot be asked to waive protections for certain specialties, when care is urgent or unforeseen, and where there is no in-network provider available (see here for more information). If you are given a waiver and do not want to consent to paying out-of-network cost sharing, contact your plan and find out if an in-network provider is available. If you believe a provider is impermissibly asking you to waive your rights or refusing you treatment, reach out to your state Department of Insurance.

To learn more about federal protections against surprise medical bills, visit https://www.cms.gov/nosurprises.

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?

All non-grandfathered plans sold to individuals and small employers must have procedures in place to allow enrollees to request and gain access to clinically appropriate drugs even if they are not on the formulary. However, that process may take time, and you may need immediate access to drugs your doctor prescribed. Therefore, marketplace insurers are encouraged to temporarily cover non-formulary drugs (including drugs that are on the plan’s formulary but require prior authorization or step therapy) as if they were on the formulary. This policy would apply for a limited time – for example, during the first 30 days of coverage – and is not required of insurers. But hopefully it will give you enough time to request an exception to the formulary so you can get your prescription covered. Note, that non-ACA plans do not have to meet the exceptions requirement.

During the COVID-19 pandemic, several states have required coverage of off-formulary drugs in certain circumstances. Contact your state Department of Insurance to see if this option might be available to you during the pandemic.

We hope that the Navigator Resource Guide has provided helpful information throughout the open enrollment process. While open enrollment for 2022 has ended in most states, it is still ongoing in a few, so check with your state’s marketplace if you still need coverage. Of course, navigating health coverage is a year-round activity. Feel free to consult the updated Guide at any time for answers to 300+ FAQs (including post-enrollment information), state-specific information, resources for diverse communities, and a feature that allows you to ask CHIR experts your private health insurance questions.