By Jay Hancock
Thu, Feb 13 2014
Congratulations. You bought insurance through one of the online Affordable Care Act exchanges, possibly after days or weeks of trying to get the site to work.
Don't relax. Joining the plan is only the first challenge. Now you have to understand it.
Policies sold through the online portals -- to more than 3 million people so far -- cover essential benefits and put a cap on your out-of-pocket medical costs.
But you need to follow the rules. And the boilerplate explanation you got from the insurance company may be hard to understand.
What do members need to know about these plans that they probably don’t?
Carry your membership card everywhere.
Make copies. It'll save huge amounts of hassle if you have an unexpected doctor or hospital visit.
Understand your plan's doctor and hospital network.
Insurance companies negotiate participation and payment rates with a network of providers to control costs.
"A lot of these exchange plans, in order to stay affordable, have much smaller networks than people are used to," says Nancy Metcalf, a senior editor for Consumer Reports. For many new members, "just because their friend has a plan and can go to a particular hospital doesn't mean that they necessarily can."
You can check a plan's directory -- either online or often part of the documents you receive when you enroll -- to find out if specific physicians are part of your network. You can call doctors' offices to confirm, too.
Stay in the network!
The health law says that, once you join a qualified plan, you won't pay more out of pocket per year than $6,350 for an individual and $12,700 for a family.
But this applies only to in-network care. Whether you’re in an HMO that pays almost no out-of-network benefits or a PPO that covers some, the pocketbook protections don't apply if you use a non-network doc or hospital.
Non-network providers also frequently bill you far more than what they charge patients in their networks for the same procedure.
Try to stay in-network even if it's for emergency care.
Insurance plans do have to pay for non-network emergency visits under the health law. If you're in a car crash far from home you can’t be picky about which hospital saves your life.
But non-network hospitals often "balance-bill" the difference between what your plan pays and what they charge, which is often much more.
Avoid all emergency rooms unless it's really an emergency.
Traditionally, health plans came with a modest copayment for an emergency visit -- maybe $150.
But many policies sold under the health law, even those in the more expensive "gold" category, not only have ER copays of several hundred dollars but also subject ER charges to the overall deductible. (Copays are flat fees for specific services. Deductibles are what you pay out of pocket before the insurance kicks in.)