• Ashley Poynter

Do you know your health insurance Marketplace rights?


Did you know that you have certain rights when you are perusing the Marketplace and shopping for healthcare plans? Yep, that’s right. There are certain things you are guaranteed in order to ensure that you have a fair shot at finding a good plan. For starters, you should be able to:


  • Find easily understandable info about what each plan covers, out-of-pocket costs for services, medications covered, and in-network providers

  • Get coverage for emergency services

  • Request health coverage for prescription drugs that may not normally be covered under your plan

  • Appeal an insurer/health plan’s decision not to pay a claim


That’s just the start. Your state may offer additional protections, so be sure to contact your state’s Department of Insurance to get full information.


Plan Info

Each plan must provide ”Summary of Benefits and Coverage” (SBC) that is easy-to-understand and that illustrates what the plan covers as well as what the associated out-of-pocket costs for those services include. The SBC also outlines coverage samples (e.g. for those with chronic conditions like diabetes or for pregnancy and childbirth) so you can see how certain medical situations might be covered — and what the total out-of-pocket costs would be — by your plan.


What’s more, each insurance company must also provide a “Uniform Glossary” that includes common terms used to describe medical care and health plan coverage. Every insurer and each plan must use standard forms for both the SBC and the “Uniform Glossary” so that plans can be easily compared.


Emergency Service Info

All Marketplace plans are required to cover emergency hospital services (barring dental plans) without needing prior authorization, even for services provided out-of-network. For instances where you do end up using emergency services that fall outside of your provider network, the plan must cover that emergency care and cannot:


  • Limit coverage to a point that is more restrictive than in-network limits

  • Charge copayments or coinsurance costs that equate to more than the cost for in-network care


The plan may require you to pay other costs, including a deductible, if this is applicable to out-of-network benefits.


Prescription Medication Info

All Marketplace plans are required to include a prescription drug exceptions process so that members can request coverage for a prescribed drug that may not initially be covered by the plan. This differs from an appeal for denial of a claim for a drug that’s covered. Each plan will have a different process in order to request coverage; however, in general, it will include having your doctor submit a request to your plan (either by mouth or in writing) that states the non-covered drug is clinically appropriate for your specific medical condition.


In some cases, the plan may provide coverage for the requested drug during the exceptions process, though this is not a requirement. Upon being granted the exception, the non-covered drug can typically be available for a dictated period of time wherein the health plan will treat the drug as covered. Even so, your share of the cost via coinsurance may apply to the most expensive tier on the formulary. In those cases, your share of the cost will still count towards your out-of-pocket maximum.


Appealing a health plan’s decision to not pay a claim

In some cases, your health plan may decide not to pay a claim; however, you do have recourse by appealing this decision. The best route to do this is to get help in the appeals process from multiple sources:


  • State Consumer Assistance Program (CAP) or Department of Insurance: Visit LocalHelp.HealthCare.gov to get access to resources in your area who can help you

  • Get help in a language other than English: Contact the Marketplace Call Center at 1-800-318-2596 or 1-855-889-4325 (for TTY users) if you don’t speak English and need help or info about the appeals process.

  • Appoint an authorized representative: This person can act on your behalf and may be an attorney, advocate, a family member, friend or other interested party. You can find the necessary forms at HealthCare.gov.


Health insurance can be complicated but it doesn’t have to be impossible. If you’re thinking about making a switch to enjoy more affordable coverage with better benefits, consider one of Decent’s plans. We center our plans around free primary care, below-market premiums, and same- and next-day appointments. Get your free quote today to see if one of our plans might be the best fit for you!

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