Half a year after policies purchased via the Affordable Care Act (ACA) online marketplace exchanges first took effect, research studies and media reports show that many of these newly insured Americans don’t understand their insurance or how to use it. “Hey Doc” is pleased to reissue some of our articles and videos to help answer some critical questions.

1. Help! I Don’t Understand My Marketplace
Insurance
A TMA “Hey, Doc” Production

2. Confusion reins in the marketplace
Half a year after policies purchased via the Affordable Care Act (ACA) online marketplace exchanges first took
effect, research studies and media reports show that many of these newly insured Americans don’t understand
their insurance or how to use it.
“Hey Doc” is pleased to reissue some of our articles and videos to help answer such critical questions as:
 How Do I Know What Coverage I Have?
 What Are Deductibles, Co-Insurance, and Co-Payments?
 What Is Covered by This Insurance?
 What Is My Marketplace Insurance ID Card For? What Do I Do If I Didn’t Get One?
 Why Is It Important to Pay My Marketplace Insurance Premium on Time?
 What Will It Cost Me to Use This Insurance?
 What Are the Limits on Out-of-Pocket Costs?
 How do I find out if my doctor is on my insurance plan’s list?
 What should I do if I thought my doctor was included, but really isn't?
 I can't find the specialist I need on my insurance plan’s list of doctors. What should I do?

3. How do I know what coverage I have
and if I can use it?
There are a few things you can do before you visit the
doctor’s office to prepare so you know what your benefits
and costs are.
First off, you want to make sure you’ve paid your premiums
on time so that your insurance takes effect. Just signing up is
not enough.
You can call your insurance company to get details on the
plan you bought. Healthcare.gov representatives should be
able to provide you a contact phone number. Talk to a
representative by calling (800) 318-2596. Or you can use a
list of marketplace plan websites that TMA compiled to find
the phone number you need.

4. How do I know what coverage I have
and if I can use it?
If you’re just now enrolling in a health plan through the
marketplace, either online or by phone, make sure you
write down the member ID number you receive. You’ll
need that number to check on your benefits when you
call your insurance company. Or if you already received
a member ID card, you can use that information when
you call.
Your insurance company also should send you a
welcome packet after you enroll. That should explain
what type of plan you bought and what your benefits
and costs are.

5. Where can I go to check my coverage?
Marketplace plan websites and phone numbers (page 1):
 Ambetter Superior
www.superiorhealthplan.com/for-members/
(877) 687-1196
 Blue Cross and Blue Shield of Texas
www.bcbstx.com/health-care-reform/health-insurance-exchange
(866) 716-5427
 Aetna
www.aetna.com/about-aetna-insurance/contact-us/forms/about/contact_us.html?WT.svl=ContactUs
(800) 872-3862
 Humana
https://www.humana.com/individual-and-family-support/contact-us
(800) 833-6917
 CIGNA
www.cigna.com/aboutcigna/contact-us/
(866) 438-2446
(800) 244-6224 (If you lost your ID card)
 Community First
www.cfhp.com/ContactUs/
(800) 434-2347

6. Where can I go to check my coverage?
Marketplace plan websites and phone numbers (Page 2):
 Community Health Choice
https://www.chchealth.org/About%20CHC/Contact_Us.aspx
(888) 760-2600
 First Care
www.firstcare.com/contact-us
(800) 884-4901 (HMO)
(800) 240-3270 (PPO)
 Molina
www.molinahealthcare.com/members/tx/en-US/hp/marketplace/pages/enroll.aspx
(855) 540-1985
 Scott & White Health Plan
https://swhp.org/members
(800) 321-7947
 Sendero Health Plan
www.senderohealth.com/en/members/member-resources
(855) 526-7388

7. What are deductibles, co-insurance, and
co-payments?
Deductibles, co-insurance, and co-payments basically describe the costs you
share with the insurance company and pay to physicians and other providers
for your health care.
Let’s start with the deductible, because that’s the amount you typically have to
pay first before your insurance starts to cover much of your health care costs.
Say you have a $1,000 deductible for the year. That means you’re responsible
for paying the first $1,000 of your medical expenses before the insurance
company helps pick up the rest. You might meet that deductible in one hospital
stay, or you could meet it throughout the year in multiple doctor visits.
Because your insurance policy covers one year at a time, you would meet that
deductible once a year, and it resets when you renew your insurance. And
depending on your plan, once you’ve met your deductible, your insurance will
start to cover a greater portion of your medical expenses.

8. What are deductibles, co-insurance, and
co-payments?
Which brings us to the co-insurance, which is different. Instead of a fixed amount, like the
deductible, the co-insurance is the percentage of a particular medical cost that you are responsible
for. Let’s say it costs $100 for an x-ray and your co-insurance is 20 percent. You would pay $20
of that cost, and your insurance would pay the rest, $80. Depending on your plan, that $20 could
go towards your deductible, or sometimes the co-insurance won’t kick in until after you’ve met
your entire deductible. And the co-insurance amount can vary depending on whether you receive
medical services in or outside of your health plan’s network.
Lastly, each time you visit the doctor, you’ll typically pay what’s called a co-payment or “co-
pay.” It’s usually a small fixed fee, like $25, that you pay up front at each visit, not something you
split with your insurance plan. But it can also vary depending on the medical service.
But marketplace plans must cover certain preventive services, like screenings and immunizations,
without making you meet your deductible, or pay co-insurance or co-payments, That’s if you get
those services in-network.
And keep in mind that the health care law puts a limit on your out-of-pocket medical expenses
each year. Once you reach that limit, your insurance usually covers 100 percent of your medical
expenses.

9. What is covered by this insurance?
All plans in the marketplace have to offer what’s called “essential health benefits.” This is a basic
package covering 10 different categories:
 Doctor visits;
 Hospital visits;
 Prescription drugs;
 Lab tests;
 Emergency room visits;
 Care when you are pregnant and when you have your baby;
 Care for children;
 Preventive services that help you stay healthy, like shots and screenings;
 Mental health care like counseling; and
 Treatments that help you recover from injuries.
Some plans might cover more than that, but that’s the minimum. You can also find dental
coverage in the marketplace, either included in a plan you buy, or separately. Marketplace plans
also must cover what are called “preexisting health conditions.” This means even if you are
already sick or pregnant

10. What is my marketplace insurance ID card for?
What if I didn’t get one?
As with most health insurance, your marketplace health plan will give you an insurance card, or
member ID card, once your insurance application is approved and you’ve paid your first premium.
Typically the card shows your name (or the head of your family’s name if it’s a family plan); a
member identification number; a group number; a phone number for your health plan; and the
type of plan you purchased. Depending on your plan, the card might include a few other pieces of
information, like your primary care doctor’s name. When you go to get health care, this
information helps your doctor, hospital, or pharmacy know what kind of insurance coverage you
have, what your visit or medications will cost, and how much you pay for versus what your
insurance company pays.
With the delays in the launch of the marketplace, some insurance companies fell behind on
processing enrollments, and a lot of people did not receive their cards. If that’s you, call your
insurance company to check the status of your application and request a card. If you still don’t
have a card by the time you need to visit the doctor or hospital, call your insurance plan ahead of
time to find out your member ID and group numbers and the type of health plan you have, and
bring that information to your visit. Also, most insurance companies are sending out welcome
letters after you sign up that show this information.

11. Why is it important to pay my marketplace insurance
premium on time?
Remember that when you buy your insurance, you pay a set monthly fee,
called a premium, to make sure it’s there for you when you need it. But for
your insurance to actually work, you have to pay that premium on time. If you
don’t, you could be responsible for paying your entire health care bill out of
your own pocket. Not paying your premiums on time also means you could
miss out on other financial help for your medical bills.
Signing up for an insurance plan is step one. And having a marketplace
insurance ID card does not necessarily mean you have active insurance
coverage unless you are paying your premiums. Once you sign up, your
insurance company will tell you when your payment is due. It will usually be
the same time each month, depending on when you first signed up. Most
health plans also offer different ways to pay your premiums, like by check or
by money order, or by mail or by automatic payments.

12. What will it cost me to use this insurance?
There are different types of costs you will pay to use your insurance.
Remember that when you first buy your insurance, you pay a set monthly fee to make sure
it’s there for you when you need it, called a premium. That premium depends on a few
things, like where you live, your age, how many people are in your family, the services you
need, and whether you smoke. Depending on your income, you might also qualify for a
subsidy to lower your premiums. So premiums are different for everyone. And it’s important
to pay those premiums on time, even when you are not using your insurance, so you are
covered when a medical issue does come up.
Then, when you go to use your insurance — at the doctor’s office, or hospital, or pharmacy,
for instance — you share some of the costs of your medical care with the insurance
company. Those costs are called deductibles, co-insurance, and co-payments. You might
hear this referred to as “cost-sharing” or “out-of-pocket costs” because while your insurance
plan helps cover a good portion of your medical expenses, you also pay for some of those
costs out of your own pocket. And those amounts depend on which type of plan you choose
and what category it falls into: bronze, silver, gold, platinum, or catastrophic.

13. What are the limits on out-of-pocket costs?
The health care law puts a limit on what you pay each year out of
your own pocket for the medical expenses covered by your
insurance, called “out-of-pocket limits.” For 2014, the out-of-
pocket limits are $6,350 for an individual plan, and $12,700 for a
family plan for the year. That’s the most you would pay for the
year, and after you reach that limit, your health plan pays for 100
percent of the services it covers. What counts toward your out-of-
pocket limits? It doesn’t include your premiums. But depending
on your health plan, it can include costs like deductibles, co-
insurance, co-pays, and sometimes care that’s out of your plan’s
network.

14. How do I find out if my doctor is on my insurance plan’s
list?
If you’re not sure if your doctor participates in your insurance plan,
there are few ways to find out.
Marketplace rules require plans to publish an online directory of
participating doctors on Healthcare.gov. It’s important to check those
lists before you buy insurance to find out if your doctor is in the plan
you want. You also can call your insurance company to check if your
doctor is in the plan. Or, the information might be included in the
welcome packet you got when you first enrolled.
You might have heard about some confusion over whether the
insurance plan lists online are up to date. So if you aren’t sure, call your
doctor directly to find out if he or she is participating in the plan you
choose.

15. What should I do if I thought my doctor was included, but
really isn't?
If your current doctor is not in your insurance plan, you have a few
options:
 If you decide to keep your doctor and he or she is not in your plan,
you may have to pay the full cost of your medical bills
 You can choose another doctor within your plan.
 Or, even if your coverage already started and you paid your
premium, the federal government recently said that you might be
able to pick another plan with your doctor, as long as the plan is
with the same insurance company and in the same “metal” level as
the one you signed up for in the first place.
 And if you do decide to switch, be sure to ask your doctor first
which plans he or she takes.

16. I can't find the specialist I need on my insurance plan’s list
of doctors. What should I do?
 Remember that insurance plans in the marketplace must sign
up enough doctors, hospitals, pharmacies, and other providers
to make sure patients can get medical care. When you don’t
have a choice and your plan’s network doesn’t include the type
of specialist you need, you can see a doctor that’s not on your
plan. But your health plan can’t charge you more than you
would pay if that doctor actually was on your current
insurance plan.
 The same thing applies if you have to get emergency care out
of network. If it’s not an emergency, be sure to call your
insurance company ahead of time to arrange to see an out-of-
network specialist.

17. HeyDoc.Texmed.Org