How health plans work: plan types (HMO/PPO/EPO/POS), metal tiers, provider networks, prescriptions, claims and appeals, preventive care, and cost-sharing.
They’re exempt from several ACA protections: no required free preventive care, no guaranteed appeal rights, no doctor-choice or ER protections, and no rate review. They must still end lifetime limits, cover adult children to 26, and provide a Summary of Benefits and Coverage.
No. A catastrophic plan isn’t a qualified health plan for the premium tax credit, so subsidies and cost-sharing reductions can’t lower its cost. If you qualify for that help, a Bronze or Silver plan is usually a better value because the savings apply to it.
Generally no. Under the Newborns’ and Mothers’ Health Protection Act, a plan that covers maternity must pay for at least a 48-hour hospital stay after a vaginal birth (96 hours after a cesarean). You and your doctor can choose to leave earlier, but the insurer can’t require it.
Yes. You can choose a Marketplace health plan that includes dental, or buy a separate stand-alone dental plan, but only if you’re also enrolling in a health plan. Separate dental plans have their own premium, and adult plans may have waiting periods.
It must be available, though you don’t have to buy it. Children’s dental (age 18 and under) is an ACA essential health benefit, so a dental option must be offered, in a health plan or as a separate dental plan. Adult dental is not an essential health benefit.
Yes, for most plans. Marketplace and most other plans must cover breastfeeding support, counseling, and equipment, including a breast pump, at no cost for as long as you breastfeed. Grandfathered plans are the main exception.
In most cases, yes. Marketplace and most plans must cover FDA-approved contraceptive methods and counseling for women with no copay, coinsurance, or deductible in-network. Certain religious employers are exempt; vasectomies and abortion-inducing drugs are not required.
Common reasons: you used an out-of-network provider, the service was billed separately from the office visit, a screening turned diagnostic, or it was not on the official recommended list. Free preventive care is guaranteed only in specific circumstances.
Possibly. The no-cost preventive rule generally applies only to in-network providers. If your plan has a network and you get preventive care out-of-network, it can charge cost-sharing or may not cover it for free.
Only in narrow cases, and only if you agree in writing beforehand. An out-of-network provider can balance-bill you for some non-emergency care only after written notice and your signed consent. You never have to sign, and consent is barred for emergency care.
Usually not. The No Surprises Act bans balance bills for certain out-of-network services (like anesthesiology or radiology) provided during a visit to an in-network facility. You pay only your in-network cost-sharing, unless you gave written consent in advance.
Yes. If you have job-based, Marketplace, or individual coverage, the No Surprises Act bans surprise bills for most emergency services, even out-of-network and without prior approval. You can be charged only your normal in-network cost-sharing.
You can appeal almost any denial of care you think should be covered, including “not medically necessary,” “experimental,” out-of-network, eligibility, or coverage-cancellation denials. Many can also go to an independent external review.
An independent organization, not your insurer, re-examines the denial and can uphold or overturn it. The insurer must accept the external reviewer’s decision by law, so it is effectively final. Federal external reviews are free; otherwise any fee is capped at $25.
You have 180 days from a denial notice to file an internal appeal, and 4 months from a final denial to request an external review. Internal appeals are decided within 30 days (before care) or 60 days (after care); standard external reviews within 45 days.
Yes. In an urgent case you can file an expedited appeal and request an external review at the same time, without finishing the internal process first. Urgent internal appeals are decided within about 4 business days, expedited external reviews within 72 hours.
An internal appeal is asking your own insurer to reconsider a denial; an external review sends the dispute to an independent third party whose decision the insurer must follow. You usually complete the internal appeal first.
Ask your plan for its medical-necessity criteria, the reason for any denial, and its comparative analysis of treatment limits. If they show stricter rules for mental health care, you can appeal and file a complaint with the U.S. Department of Labor.
For most people, yes. Marketplace and other individual and small-group plans must cover mental health and substance use treatment as an essential health benefit; large-employer plans usually do but are not required to.
If your plan covers out-of-network medical care, parity requires it to cover out-of-network mental health and substance use care on comparable terms. It does not force a plan with no out-of-network medical benefits to add them.
Union employees usually get coverage through a multiemployer, or Taft-Hartley, plan jointly run by unions and employers. Employers contribute to a trust fund at a rate set by the collective bargaining agreement, and eligibility is based on hours worked.
Generally no. HMOs cover only in-network providers except for emergencies and pre-authorized referrals; routine out-of-network care is the member’s full responsibility.
In an HMO you pick a primary care physician who coordinates your care and must issue a referral before the plan will cover a visit to a specialist.
An HMO is a managed-care plan that keeps costs low by requiring you to use in-network providers and choose a primary care physician who coordinates your care and refers you to specialists.
Pros: lower premiums than a PPO and usually no referrals. Cons: no out-of-network coverage except emergencies, so you must stay in network.