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When you need emergency care, you can go to any ER, whether it's in or out of your insurer's network, and it will be paid the same. However, you may be subject to balance billing by an out-of-network provider. If your insurer says you need a primary care physician, you pick any doctor that accepts your insurance and is accepting new patients. If you have kids, you pick the pediatrician. Women can see an OB/GYN that accepts their insurance without getting approval from the insurance company or a referral from a primary care doctor.
Do you have a child under 19 years old? He or she can't be denied coverage because of a "pre-existing condition." A pre-existing condition is a health problem that was treated under a different health insurance company. Or, your child had the health problem before you enrolled him or her for health insurance coverage.
In the past, health plans could put a limit on how much your plan would pay in any one year. This annual dollar limit is being phased out and will be gone by 2014. So your coverage won't run out if you have a bad year.
If your health plan denied payment for a service or treatment, you can appeal the decision. If payment is still denied, you can ask for a review from a third party called an Independent Review Organization (IRO). Depending on the denial reason, the IRO may overturn the decision and require the claim to be paid.
Mistakes happen. Now, an insurer can't cancel your health insurance unless you made an intentional misrepresentation or committed fraud on your insurance application.
Health plans cannot set a lifetime dollar limit on benefits you receive. That means your coverage won't run out, even if you have a costly medical condition. Frequency and visit limits can still apply for some things like hearing aids and chiropractor visits.
Preventive care, like screenings, vaccinations and physicals, is covered at no cost. That means you do not have to pay a copay, coinsurance or deductible as long as your doctor is part of your health insurance network.
People covered under your plan can stay covered until they're 26 years old. They're even covered whether or not they live with you, are a full-time student, are married, or have children of their own.
The Affordable Care Act gradually closes the gap in Medicare drug coverage (Part D) between now and 2020. This gap is known as the "donut hole." In 2010, a one-time, tax-free $250 rebate was given to help pay for prescriptions. In 2011 and 2012, discounts were given on generic and brand-name drugs.
People who are disabled often need special care. They also do better living at home rather than in nursing homes or assisted living facilities. That's why the government is giving more money to states for home care through Medicaid. It's called the Community First Choice Option.
We all want better health care at lower costs. That's why the Centers for Medicare and Medicaid Innovation is working to improve Medicare, Medicaid and the Children's Health Insurance Program.
It works to: help you get the right treatment, help doctors work together when treating the same person for different health concerns, and make sure the right treatment is provided at the right time. End result? You pay less for better, safer care.
Are you worried that Medicare may not be here when you're older? The federal government is taking steps to make sure that Medicare lasts and you pay less for premiums and your care.
The government is working on reducing Medicare fraud, waste and mistakes. With these changes and other steps to improve the quality of care, the Medicare trust fund should be around to at least 2024.
Nearly one in five senior citizens end up back in the hospital within 30 days of being hospitalized for an illness or surgery.
That's why the Community Care Transitions Program was created. It will help high-risk patients after hospital stays, by bringing care right to the community. Health programs will be available to senior citizens near their neighborhood - so the care doesn't stop when they leave the hospital.
Health insurers must spend at least 80 to 85 cents of every premium dollar to pay health care claims or improve the quality of care. This is called the medical loss ratio. It makes sure that premiums are spent on care rather than administration and overhead.
If insurers don't follow this rule, they must pay rebates to employers or members.
Seniors who reach the coverage gap get 50% off when buying Medicare Part D covered brand-name prescription drugs.
While in the coverage gap, seniors can save money on covered brand-name and generic drugs until the gap closes in 2020.
Seniors don't need to do anything to get the discount. They should work with their drug plan to make sure that their drug records are correct.
If you're covered by traditional Medicare, you're eligible for free yearly wellness visits and other preventive services and tests.
This coverage also includes help on how to quit smoking and screenings for cancer and other diseases.
Do you have a health care spending account, like an FSA, HSA or MSA? If so, your account can help pay for medical, dental and vision expenses, and some over-the-counter medications prescribed by a doctor.
Important tip: Make sure you use your account only for qualified medical expenses. If you don't, you may have to pay a tax penalty. Your spending account details should list which expenses are qualified.
Medicare rewards hospitals that provide better care by paying them a higher reimbursement rate. Medicare payments are based on a program called Value-Based Purchasing. The program measures how well hospitals handle cases such as heart attacks, surgery and infections.
Electronic Health Records (EHRs) are in. Print records are out. Doctors, hospitals and health plans share a secure electronic system to keep your records organized and available wherever you are. Less paperwork, more efficiency. With everyone on the same page, you can get better service and better care.
Two out of three people in the U.S. over age 65 have more than one health problem and see multiple doctors.
When doctors work together, you can stay healthier. That's why health care reform offers incentives - through Accountable Care Organizations (ACOs) - for doctors to better work with each other when treating Medicare patients.
Low-income Americans and some racial and ethnic groups can face barriers to getting the care they need. Culture, language and education can all play a part. Studies are looking at how these groups interact with the health care system and possible improvements, such as lower costs for preventive care, cultural training for doctors and funding for health centers.
If you're a woman, a lot of preventive services are covered at 100%. That means no copays or coinsurance, as long as you use a doctor in your insurance network.
All health insurance plans now cover: well-woman visits, gestational diabetes screenings, testing and counseling for sexually transmitted infections, FDA-approved birth control methods, breastfeeding support and more. However, certain religious employers can opt out of birth control coverage.
In a major court ruling, the United States Supreme Court upheld the Affordable Care Act (health care reform).
What does it mean to you? It means changing our health care system is, in fact, "constitutional." And, because of the ruling, health care reform is on track through 2014.
Every insurance company now sends the same type of easy-to-understand coverage summary. This new document is called a Summary of Benefits and Coverage (or SBC).
It tells you the basics of what's covered, what's not, and your estimated cost for care. It also lets you compare costs of treatments. The result? You have an easier time choosing the best coverage.
You can set aside up to $2,500 for your medical Flexible Spending Account (FSA) per year. FSAs, also called Flexible Spending Arrangements, are deducted from your paycheck by your employer and aren't taxed. These funds can be used to pay for certain types of health expenses.
States get funding for the Children's Health Insurance Program (CHIP) until September 30, 2019. This low-cost program covers children up to 19 years old. It helps families that can't afford health insurance but don't qualify for Medicaid. All states have a CHIP program but may have a different name for it.
With health care reform, you're required to have health coverage. As of October 2013, there's one more way to get a health plan. It's called the health insurance marketplace (also known as exchanges). It gives you one more way to compare and buy health insurance. Keep in mind, you can still buy plans from a health insurance company - or choose your employer's plan.
States get more funding for Medicaid programs that cover preventive care services at 100%. The goal is for more Americans covered by Medicaid to have access to preventive care, like vaccines, physicals and screenings.
If you choose to help improve science by being part of a clinical trial, you'll still need traditional health care.
Companies can't deny health coverage to people in research studies or who are getting treatments not yet approved by the FDA.
In the past, health plans could put a limit on how much your plan would pay in any one year. This annual dollar limit will be fully phased out by 2014. So your coverage won't run out if you have a bad year.
For individual and small group employee plans, health insurers cannot charge a higher or lower rate based on your gender.
Health insurers cannot refuse to cover you or renew your plan because of a pre-existing condition such as cancer, asthma, high blood pressure or arthritis. If you have a condition, you will still be able to get health insurance coverage.
Most adults under 65 who earn up to $15,000 a year can sign up for Medicaid coverage in every state. A family of four with an income up to $29,000 a year can also get Medicaid coverage.
The federal government will give the states extra money to help them pay for this coverage.
If you buy coverage through your state's health insurance marketplace, you may qualify for a tax credit or subsidy. Your earnings have to be below a certain level. Also to qualify, you can't have access to other affordable coverage through an employer-sponsored plan or other state-assisted coverage like Medicaid.
The law states all legal U.S. residents to have basic health insurance coverage, if they can afford it. This part of health care reform is called the individual mandate. It's meant to make health care more affordable for everyone. If you don't have insurance, you will likely pay a tax penalty. Special cases may be able to get an exception.
People who can get health insurance through their jobs often do. Health care reform offers one more way of getting health care - through the health insurance marketplace (also known as exchanges). In short, you still have the same choices for getting coverage as you did before, plus the marketplace.
Log in or use the identification number on your member ID card to find a doctor or hospital in your plan’s network.
If it’s not an emergency (and you can’t get to your regular doctor) - there are other options for fast, more affordable care.