Health Insurance Consumer Guide

Basic Insurance Terms

Accumulation Period: The period of time during which an insured person incurs eligible medical expenses toward the satisfaction of a deductible.

Claim: A bill for medical services rendered, typically submitted to the insurance company by a healthcare provider.

Cost-sharing: Health care provider charges for which a patient is responsible under the terms of a health plan. Common forms of cost-sharing include deductibles, coinsurance, and co-payments. Balance-billed charges from out-of-pocket physicians are not considered cost-sharing.

Co-payment: A specific charge that your health insurance plan may require that you pay for a specific medical service or supply, also referred to as a “co-pay.” For example, your health insurance plan may require a $15 co-payment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.

Deductible: A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most Indemnity and PPO plans do

Group: A number of individuals covered under a single health insurance contract, usually a group of employees.

Network: A “Network” plan is a variation on a PPO plan. With a Network plan you’ll need to get your medical care from doctors or hospitals in the insurance company’s network if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it’s up to you to make sure that the health care providers you visit participate in the network. Services rendered by out of network providers may not be covered or may be paid at a lower level.

Premium: The total amount paid to the insurance company for health insurance coverage. This is typically a monthly charge. Within the context of group health insurance coverage, the premium is paid in whole or in part by the employer on behalf of the employee or the employee’s dependents.

How Can My Health Insurance Help Me?

  • Paying For Prescriptions
  • Getting Regular Medical Care
  • Getting Emergency Care

Paying for Prescriptions

Health plans will help pay the cost of certain prescription medications. Medications on your plan’s approved (also called “formulary”) list are either completely or partially covered.

How do I know if my prescription is completely or partially covered?

To find out which prescriptions are covered through your new Marketplace plan:

1. Visit your insurer’s website to review a list of prescriptions your plan covers

Molina - Coming Soon!

Magnolia Website

2. See your Summary of Benefits and Coverage

3. Call your insurer directly to find out what is covered. Have your plan information available. The number is available on your insurance card the insurer’s website, or the detailed plan description in your Marketplace account.

Molina (Coming Soon)

Magnolia Call Center: 866-912-6285

4. Review any coverage materials that your plan mailed to you.

What if my plan no longer covers my prescription?

What do I do if I’m at the pharmacy to pick up my prescription, and they said my plan no longer covers it?

Some insurance companies may provide a one-time refill for your medication after you first enroll. Ask your insurance company if they offer a one-time refill until you can discuss next steps with your doctor.

If you can’t get a one-time refill, you have the right to follow your insurance company’s drug exceptions process, which allows you to get a prescribed drug that’s not normally covered by your health plan. Because the details of every plan’s exceptions process are different, you should contact your insurance company for more information.

Generally, to get your drug covered through the exceptions process, your doctor must confirm to your health plan (verbally or in writing) that the drug is appropriate for your medical condition based on one or more of the following:

Can I go to my regular pharmacy to get my medication?

Just like different health plans cover different medications, different health plans allow you to get your medications from different pharmacies (called “in-network pharmacies”). Call your insurance company or visit their website to find out whether your regular pharmacy is in-network under your new plan and, if not, what pharmacies in your area are in-network. You can also learn if you can get your prescription delivered in the mail.

Get regular medical care

Most health plans give you the best deal on services when you see a doctor who is an in-network provider it usually means you’ll have lower out-of-pocket costs.

Finding a doctor in your plan

To find out if your doctors and other health care providers are covered by your new Marketplace plan, or to find a covered provider if you don’t have one yet:

1. Visit your health plan’s website and check their provider directory, which is a list of the doctors, hospitals, and other health care providers that your plan contracts with to provide care.

2. See your health plan’s provider directory. You can get this by contacting your plan, visiting the plan’s website, or using a link that you’ll find on the plan description in your Marketplace account.

3. Call your insurer to ask about specific providers. This number is on your insurance card and the insurer’s website.

4. Call your doctor’s office. They can tell you if they accept your health plan.

5. Call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). A trained representative can help you find your insurer’s number

Is there an appeals process?

Is there an appeals process if I go to my regular doctor and find out later that my new plan doesn’t cover them?

Mississippi’s federally designated consumer assistance program is Health Help Mississippi. Health Help can assist you and your family if you have been denied benefits or have trouble accessing insurance coverage. Health Help is your representative when you have a problem with your health insurance plan.

Get emergency care

In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can’t charge you more for getting emergency room services at an out-of-network hospital.

I’m having an emergency. Should I go straight to the hospital or do I need to call my insurer first?

In a true emergency, go straight to the hospital. Insurers can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.

What does it mean that insurance companies can’t charge me more?

Insurance plans can’t make you pay more in copayments or coinsurance if you get emergency care from an out-of-network hospital. They also can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.

Will I have to pay for my emergency hospital visit?

This depends on the plan that you chose and the hospital you go to. This care may be subject to a deductible, for example, or a hospital may have particular rules in place.

Appealing an insurance company decision

If your health insurance company doesn’t pay for a specific health care provider or service, you have the right to appeal the decision and have it reviewed by an independent third party.

Your insurance company must first notify you in writing within a set amount of time (based on the type of claim you filed) to explain why they denied coverage. They also must let you know how you can appeal their decisions.

If the timeline for the standard appeals process would seriously put your life at risk, or risk your ability to fully function, you also can file an appeal that would get you a quicker (or “expedited”) decision. If you meet the standards for an expedited external review, the final decision about your appeal must come as quickly as your medical condition requires, and no later than 72 hours after your request for external review is received.

If you have questions contact Health Help Mississippi at 601-354-3470 or 1-877-314-3843

Using coverage and improving your health

Now that you have health coverage, learn what you can do to stay healthy and get the care you need.

Read the Roadmap to Better Care and a Healthier You for tips and information on:

  • Putting your health first
  • Understanding your coverage
  • Finding a provider
  • Making an appointment
  • Preparing for your first visit
  • Deciding if you like your provider
  • Taking your next steps to good health