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Health insurance is an important coverage that helps protect you and your family from the devastating financial effects of unexpected health problems or catastrophic illness and as of January 1, 2014, most Americans are now required by Federal Law to have health insurance or pay a penalty.
The Oklahoma Insurance Department encourages you to work with the insurance professionals in your community to help you determine the appropriate policy for your family or business needs. These insurance professionals can be found on our website under:
You may receive health coverage through an individual insurance policy, through a policy issued to you as a member of an association group, through an employer sponsored health plan or through a government plan (Medicare, SoonerCare (Medicaid), VA, etc.). If your employer sponsored health plan is “self insured” it is not subject to regulation by the Oklahoma Insurance Department but regulated by the Department of Labor. Additional information regarding employer sponsored plans is available below. The three main types of health insurance are:
Click the image above to find out which private insurance plans, public programs and community services are available to you.
Traditional Health Insurance
With the passage for the Affordable Care Act or Healthcare Reform in 2010, most traditional health insurance plans, often called "fee-for-service," are most likely now to be found in “Grandfathered Plans”, non-compliant ACA plans or commonly known as “Grandmother Plans” or Medicare Supplement Plans. If your plan is a true “free for service”:
ACA compliant group health and individual policies fall under the category of comprehensive medical policies. These ACA compliant policies are expensive because they are required by Federal law to provide more benefits than many older or pre-ACA policies. An ACA compliant policy pays a percentage of covered expenses (for example, 60%, 70%, 80% or 90%), after you pay the applicable plan deductible and copays. The remaining expense (for example,10%, 20%, 30% or 40%) is coinsurance and is paid by you. Maximum out-of-pocket limits restrict the amount of coinsurance you pay. After the covered person or family reaches their maximum out-of-pocket limit, your plan will pay 100% for that person or family for the rest of that year. Pay particular attention to the plan’s maximum out of pocket limit before you buy a plan particularly if you are not eligible for cost sharing reductions on the federal exchange.
Policies that provide Managed Care Services
ACA compliant policies will often be tied to a provider care network. This affects your choice of doctors and hospitals because not all providers are part of the network. In return for this limited choice, you usually pay less for medical care (i.e., doctor visits, prescriptions, surgery and other covered benefits) than you would with traditional “fee-for-service” health insurance. The managed care network controls health care services in these narrower network options Be sure to review all providers available to you under each type of Managed Care Service network you choose.
If your health care provider is out-of-network, you are responsible for the difference between the allowed amount and the provider's charge and those amounts will not be applied toward your out-of-pocket limits. It is imperative that you contact your insurer should you have any question regarding a health provider being an in-network or out-of-network provider. Out- of- network providers can be far more costly as they are not subject to your insurer’s provider contract/s or discounted fee for services, however ACA compliant polices must cover emergency services received by an out-of-network provider as if they were in-network.
The types of Managed Care Networks are:
Limited Benefit Coverage Plans
Limited benefit health plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans, not to be an alternative to them. You may have seen these types of plans marketed as Accident Policy, Cancer Only, Specific Disease or Heart Policies, Hospital Cash or Indemnity plans. They may also be Discounted Plans such as Pharmacy, Dental or Medical Clinic Memberships. These plans are not considered ACA compliant which could result in you paying additional out-of-pocket expenses for uncovered medical services and a fee or tax if you do not have a comprehensive health insurance plan as your primary plan.
Limited benefit health insurance plans are not typically required to provide the same level of coverage, so they cover fewer types of medical services and expenses than a comprehensive policy. These plans typically pay you a flat amount for a specific service, covered item or covered disease or giving you a discount for services, leaving you the rest of the bill to pay yourself. A limited benefit plan may limit the amount of coverage the company will pay per episode of illness or per day, sometimes as low as $50 to $5,000 (not counting co-insurance and deductibles paid out-of-pocket by you). These policies also provide limited surgical, preventative care, testing and emergency benefits upon receipt of the billing. And with low maximum benefit limits called “caps,” it may be possible for you to reach your cap quickly, leaving you responsible for the balance of the bill. Discounted plans still leave you paying for the services yourself.
Buyer beware when purchasing Limited Benefit Plans – understand what you are purchasing!
Other types of plans:
How do I Purchase Health Coverage?
Individual vs. Group Coverage
There are two basic ways to buy health coverage: as an individual or through a group. How you buy health coverage affects your rights and responsibilities.
Group Coverage can be purchased outside of the exchange through an agent or broker or directly from the carrier. Small employer groups (until the end of 2015, those with 50 or fewer employees) can purchase through an exchange called the SHOP.
A group insurance policy may cover two to thousands of people, but it is still only one policy.
The master policyholder can:
In a group contract
Large and small employer group contracts
Other ways you can be covered for Health Care is through a government sponsored program like Medicare, SoonerCare (Medicaid) or VA, etc.
Other Policy Information
What Expenses will I have In Addition to My Premium?
ACA compliant policies have maximum out-of-pocket limits and unlimited lifetime benefits which limits your liability or exposure (how much of the expenses you have to pay yourself). However, out-of-network charges, except in emergency situations, are your responsibility and you may be balanced billed so you must read your policies very carefully and know that your provider is in network before using their services.
How Do I let the Insurance Company Know When I Have a Claim?
When you use an In-Network provider, your provider will file the claim directly with your insurance carrier. You will receive an Explanation of Benefits of how that bill was paid and what your responsibility is, if any. If there is a dispute, contact your insurance carrier customer service department for a resolution, first. Ask for a resolution time frame. If not completed by that time and the explanation seems unreasonable, contact Consumer Assistance at the Oklahoma Insurance Department for help or assistance in appealing.
If your treatment bill has been denied by your insurance carrier, follow these steps to begin the appeal process:
Please refer to the How To Appeal sheet enclosed with your Explanation of Benefits received from your insurance carrier on your denied services. For further help, contact your insurance carrier Customer Service Helpline or the Oklahoma Insurance Department Consumer Assistance Department.
Can an Insurance Company Exclude Pre-Existing Conditions?
With the passage of the Affordable Care Act in 2010, eligible children could not be denied insurance coverage due to poor health or prior treatments and beginning January 1, 2014, all eligible persons applying for insurance could not be denied coverage due to poor health or prior treatments.
Click here to see how pre-existing conditions are now protected. This provision applies to policies sold on and off the exchange.
What Happens If I am Late With My Premium Payment?
If you bought a policy on the federal health exchange and you are receiving premium tax credits, you have certain protections when you are late paying your premium. Please contact www.healthcare.gov at 1-800-318-2596.
If you bought a policy outside of the federal health exchange you should contact the insurance carrier’s customer service department who will give you instructions and your options.
Can I Cancel My Policy?
If you have a policy through the federal health exchange, please click here.
If you have a policy outside of the federal exchange, contact your insurance agent or broker who sold you the policy or your insurance carrier’s customer service department who will give you instructions and your options.
Can I Get My Policy Back If It Gets Canceled?
You have certain rights and protections both inside and outside of the exchange. However, when an insurance carrier leaves the marketplace, you must follow the instructions you receive from your insurance carrier and take notice of your deadlines to take action.
Is My Family Included in My Policy?
You have the option of covering your entire family or not at the time of application or during Open Enrollment.. Read the policy and the schedule page to determine who is insured under the policy.
What Are My Benefit Limits?
You will want to refer to your Summary of Benefits and or Policy for your out of pocket limits. Policies can no longer have annual or lifetime limits for essential health benefits. For policies bought through the federal health exchange, please click on the following link: