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Maine.gov > PFR Home > Insurance Regulation > Affordable Care Act (ACA) FAQ >Shopping For Health Insurance: What Is Covered?

SHOPPING FOR HEALTH INSURANCE COVERAGE: WHAT IS COVERED?

Q 14: What types of plans will be available through Maine’s Health Insurance Marketplace?

Health plans sold through Maine’s Health Insurance Marketplace will be required to meet comprehensive standards for items and services that must be covered. To help consumers compare costs, plans will be organized in four tiers of cost-sharing:

  • Bronze level – The plan must cover, on average, 60% of expected costs, while the consumer pays, on average, 40% in deductibles, copayments, and coinsurance. This is the lowest level of coverage available to everyone who buys through the marketplace.
  • Silver level – The plan must cover 70% of expected costs, the consumer 30%.
  • Gold level – The plan must cover 80% of expected costs, the consumer 20%.
  • Platinum level – The plan must cover 90% of expected costs, the consumer 10%. This is the highest level of coverage.

It is important to understand that a particular consumer’s actual cost sharing for deductibles and other cost sharing will likely be more or less than the average consumer’s “expected costs.”  A consumer with a silver plan and low medical expenses will pay more than 30% of the costs, while a consumer with the same plan and high medical expenses will pay less than 30%, because the plan pays all covered expenses once they reach the out-of-pocket limit.

Also, a catastrophic plan will be offered. It will cover the same services, but its coverage will be slightly less generous than the Bronze level plans. A catastrophic plan may be a less expensive option for those who are eligible: only young adults under 30 and individuals who have a hardship exemption from the individual mandate are allowed to buy catastrophic plans. Subsidies  aren’t available for catastrophic plans.

Also, stand-alone dental plans are available through Maine’s Health Insurance Marketplace.

Q 15: How do the tiers (bronze, silver, gold and platinum) help consumers compare plans?

The tiers are a way to categorize plans based on “actuarial value.” Plans within each tier have a similar actuarial value, even if they cover different benefits or have different types of cost-sharing. While all plans must cover essential health benefits, the details of their coverage (such as how many physical therapy visits are covered or which prescription drugs are covered) may be different. Not all plans in the same tier have the same benefits or cost-sharing requirements. Some plans may offer benefits in addition to the essential health benefits.

Q 16: What is actuarial value?

Actuarial value measures the percentage of total average costs that the plan pays for the essential health benefits. The percentage of total average costs the plan pays depends on the cost-sharing details—how much the consumer pays out-of-pocket for deductibles, coinsurance, and copayments and the out-of-pocket limits.

Actuarial value is calculated for a standard population and doesn’t mean that the plan will pay that percentage of a person’s actual costs. For instance, a silver tier plan will pay more than 70% of medical expenses for some people and less for other people.

Actuarial value only reflects differences in cost-sharing. It doesn’t give any other information about a plan that may be important to a particular person. It doesn’t tell you whether the plan provides more than the required essential health benefits, how broad or narrow a plan’s provider network is, the quality of the provider network, the plan’s customer service and support, or how broad or narrow the drug formulary is. All this information is important for consumers to consider when they choose a plan.

FOR MORE INFORMATION:  www.healthcare.gov/how-do-i-choose-marketplace-insurance 

Q 17: Which insurance companies will offer coverage through Maine’s Health Insurance Marketplace? How can a consumer get a list of plans available?

Anthem Blue Cross and Blue Shield, and Maine Community Health Options will be offering major medical plans through Maine’s Health Insurance Marketplace.  A summary of the plans these insurers will offer is available at http://www.maine.gov/pfr/insurance/ACA_Index.html

Q 18: What are essential health benefits?

After January 1, 2014, almost all plans sold in the individual and small group market, including those sold through Maine’s Health Insurance Marketplace, must cover, at a minimum, a comprehensive set of benefits known as essential health benefits. These essential health benefits include benefits in the following categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services, including chronic disease management
  • Pediatric services, including oral and vision care 

For a detailed list, see “Maine’s Benchmark Essential Health Benefits Checklist” on the Life Health Checklist page of the Bureau of Insurance website: http://www.maine.gov/pfr/insurance/review_checklists/life_health.htm

Q 19: Can a person buy only some of the benefits in a plan if he or she doesn’t need all the benefits?

No, consumers can’t take benefits out of a plan, but they may be able to add extra coverage. At a minimum, every health plan on Maine’s Health Insurance Marketplace must provide coverage for all of the essential health benefits the ACA requires . Even though a person may not need every essential health benefit in a plan, plans must cover all of them to share risk across a broad pool of consumers and be sure all benefits are available for everyone. This also helps protect people from risks they can’t always predict across their lifetimes.

Pediatric dental benefits get slightly different treatment.  If these benefits are not embedded in the major medical plan, an individual must be offered the opportunity to buy a stand-alone dental plan.  However, the individual doesn’t have to buy a plan with that benefit if it is not needed.

Q 20: What are preventive benefits and how are they covered?

Preventive benefits are designed to keep people healthy by providing screening for early detection of certain health conditions or to help prevent illnesses. The ACA requires that plans cover many preventive services with no out-of-pocket costs (meaning no deductibles, co-payments, or coinsurance) for all new plans beginning Sept. 23, 2010. Some of these covered preventive services are:

  • Colorectal cancer screenings, including polyp removal for individuals over age 50
  • Immunizations and vaccines for adults and children
  • Counseling to help adults stop smoking
  • Well-woman checkups, as well as mammograms and cervical cancer screenings
  • Well-baby and well-child exams for children

Unless an insurer doesn’t have an in-network provider to do a particular preventive service, plans can charge for these preventive services when done by an out-of-network provider.

For the exact list of covered preventive services, visit the federal government’s website at:
www.healthcare.gov/what-are-my-preventive-care-benefits.

Q 21: How does a consumer find out what drugs a plan covers?

Health insurers keep lists of which drugs are covered and which are covered at the lowest cost for each of their plans, called formularies. Drug cost-sharing is often “tiered”; that is, consumers pay less for a generic drug, more for a brand name drug, and sometimes even more for a non-preferred brand name drug or a specialty drug. Consumers should review the formularies in any plan they select to be sure they meet their prescription drug needs and to know what cost-sharing is required. For plans that use formularies, the SBC includes a website (or similar contact information) with information about the plan’s drug coverage. Consumers also can call their health insurer for help.

Q 22: How can a consumer find out the details about what a particular plan covers?

All individual and small group plans that aren’t grandfathered plans offered after January 1, 2014, will cover essential health benefits.

Check a plan’s Summary of Benefits and Coverage (SBC). An SBC includes details about what a plan does and doesn’t cover. It also includes information about what kinds of costs a consumer can expect to pay out-of-pocket, such as copayments, coinsurance, and deductibles. It gives information in the same way for every plan to make it easier to compare plans.  Every insurance company and group health plan must give consumers a Summary of Benefits and Coverage (SBC) and glossary of commonly used terms both before they enroll and each year at plan renewal time.

Maine’s Health Insurance Marketplace website at www.healthcare.gov  will include information about what each plan covers and links to the insurer’s plan brochures.

FOR MORE INFORMATION:
www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/Summary-of-Benefits-and-Coverage- and-Uniform-Glossary.html.

Q 23: How can consumers further understand what a plan covers?

In addition to getting an SBC, starting on October 1, consumers also will be able to get information about the health plan options available at Maine’s Health Insurance Marketplace website at www.Healthcare.gov, through its toll-free telephone number (1-800-318-2596 for individuals or 1-800-706-7893 for small businesses), or from navigators or consumer assisters.  Http://www.enroll207.com/locator/ enables consumers to type a zip code and find out how to contact their closest navigators and consumer assisters.  Consumers can also dial 2-1-1 for information on navigators.

Q 24: How can consumers compare prices for plans?

Maine’s Health Insurance Marketplace is set up to let consumers compare policies on the basis of price, provider network, actuarial value, and other factors. Consumers can get this information from Maine’s Health Insurance Marketplace website at www.Healthcare.gov or call center at 1-800-318-2596 for individuals or 1-800-706-7893 for small businesses. Also, navigators, certified application counselors, insurance agents or brokers, and other assistors should be able to help consumers compare plans. Check  http://www.enroll207.com/locator/ or dial 2-1-1 for navigator assistance. 

Consumers won’t be able to see the cost of a specific benefit unless a stand-alone plan – such as an adult dental plan -- provides that service or benefit. Check Maine’s Health Insurance Marketplace website at www.Healthcare.gov for additional information.

Q 25: Can an insurance company charge smokers more than non-smokers?

Yes, under the ACA, health insurance companies can ask about tobacco use before they enroll a consumer in a plan, and then can charge consumers who use tobacco products a higher premium. Some insurers will be doing this and others will not. Consumers in group plans may not have to pay this extra charge if they complete a tobacco cessation program.

Q 26: Can a person’s health condition affect their coverage?

No. Under the ACA, health insurance companies can no longer exclude benefits related to a person’s health condition, often called “preexisting condition exclusions.” This protection applies whether a person buys coverage on or off the marketplace.

Q 27: Are dental or vision benefits available through Maine’s Health Insurance Marketplace?

The ACA requires plans sold through Maine’s Health Insurance Marketplace to include vision coverage for children, but there’s no process to offer a stand-alone vision plan.

Dental benefits are treated differently. The ACA lets insurance companies offer health plans through Maine’s Health Insurance Marketplace that don’t include children’s dental benefits, so long as the Marketplace offers a stand-alone dental plan that includes a pediatric dental benefit.

Plans offered through Maine’s Health Insurance Marketplace aren’t required to include dental or vision coverage for adults, but a plan can choose to include these benefits. Check a plan’s SBC to learn if the plan includes dental or vision coverage for adults. 

Some insurance companies may offer stand-alone dental plans through Maine’s Health Insurance Marketplace. Check www.healthcare.gov for more information. As long as a consumer has minimum essential health coverage, he or she isn’t required to buy health insurance from a company if he or she simply wants to buy a stand-alone dental plan. 

If a plan does include dental coverage, those services may be included in the plan’s maximum deductible. Buying a stand-alone dental plan may result in having to pay a separate deductible.

Q28: Do consumers have coverage for covered benefits provided by out-of-network providers?

Services are considered to be provided out-of-network if they’re from a doctor, hospital, or other provider that doesn’t have a contractual relationship with a particular health plan. Not all plans cover out-of-network services, but when they do, a consumer’s share of the cost is usually a lot higher than for an in-network service. Though the ACA limits how much money a person is required to spend on his or her family’s health care, out-of-network services don’t count toward these limits.

Consumers may want to find out if their regular health care providers are in-network before they buy a plan. Consumers may also want to find out whether a provider is in-network before they receive services.

A plan’s SBC will include information about coverage for out-of-network services.

Q 29: How do consumers determine if their doctor or dentist is in the network?

Maine’s Health Insurance Marketplace website (Healthcare.gov) lets consumers look up whether or not their doctor is in the network plans. For plans with a provider network, the SBC includes an website link or similar contact information for getting a list of network providers. It’s always a good idea to also check with the doctor or dentist before you schedule an appointment to learn if the information on the website is up-to-date.

Q 30: Do consumers have access to emergency care out-of-network?

Yes, the ACA requires any health plan that provides benefits for emergency services to cover them regardless of whether the provider is in or out of the network, and it cannot charge a higher copayment or coinsurance for out-of-network services received in an emergency. In addition, Maine prohibits balance billing for emergency care received out-of-network, the consumer’s share of the cost for emergency care must be based on in-network rates.

 

Last Updated: October 8, 2013