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FAQs

Frequently Asked Questions

What is the new health care law?

Passed in 2010, the Affordable Care Act is a new health care law designed to give people more ways to get health insurance. There are five important parts of the new law:

  • Guaranteed Issue
    • You cannot be denied coverage regardless of your health, age, gender or other factors that might predict your use of health services.
  • Cost Assistance
    • You may qualify for tax credits or additional government – funded subsidies to help pay for the cost of your health insurance.
  • Individual mandate
    • Most individuals will be required to purchase health insurance or pay a penalty tax.
  • Preventive services
    • Preventive services are now covered at 100% with zero out-of-pocket cost to you.
  • Limitation exclusions
    • Plans will no longer place dollar limits on the amount of covered health care services provided by the plan.

How does the new health care law affect me?

If you already have health insurance, you may not experience any changes. Or, you may find insurance that covers additional benefits. If you do not have health insurance because of a pre-existing condition or for financial reasons, you will find there are more affordable options available to you.

Am I required to have health insurance? What happens if I don't?

Under the new law, most individuals will be required to have health insurance in 2014. If you do not have it, you may have to pay a penalty on your federal income tax return.

What are premium tax credits and who is eligible to receive them?

Premium tax credits assist with up-front payments to offset the monthly cost of health insurance. Individuals and families with incomes between 100% and 400% of the Federal Poverty Level (FPL) who purchase coverage in the newly established Health Insurance Marketplace may qualify.

How do premium tax credits work?

Advance payments are made directly to the insurance company that the individual chooses, with individuals responsible for the remaining premium. The credits are delivered in advance so that individuals do not have to pay the full premium and wait to be reimbursed.

Can I get coverage even with a pre-existing health care condition?

Yes. Under the Affordable Care Act, health plans like Community will offer health coverage, regardless of pre-existing medical conditions, starting in January 2014.

My daughter just turned 21 and lives at home, but she isn’t a full-time student. Can she get health care coverage?

Yes. Your adult children can be covered under your plan until they are 26 years old or can apply for coverage on their own.

What are the benefits provided by Community’s affordable health care coverage?

Community Health Choice will include benefits considered to be essential to good health. The Affordable Care Act defines these as essential health benefits. Essential health benefits include:

  • emergency services
  • hospitalization
  • maternity and newborn care
  • preventive/wellness services
  • mental health/substance abuse services
  • prescription drugs
  • rehabilitative services and devices
  • laboratory services
  • ambulatory patient services

A full list of Community Health Choice plan benefits and rates are available under the Benefits and Coverage section.

What is the Federal Poverty Level (FPL) and how does it affect me?

The Federal Poverty Level is the minimum yearly income that a person or family needs in order to provide for its basic needs. The Department of Health and Human Services calculates the FPL and the actual dollar amount varies according to family size. 2016 Federal Poverty Level

How long do I have to pay my first invoice?

You have 30 days from when you first sign up for your plan to make your first payment. You can expect to receive your first invoice 3-5 business days after you sign up for your plan.

You do not have coverage until you make this first payment.

If you do not make your first payment within 30 days, you will be dis-enrolled from your health plan.

When is my premium due?

Your premium is due before the first of each month. After that, it is considered late. This payment is for the upcoming month of coverage.

For example, a payment that you make on February 28th is for March coverage.

When can I use health insurance?

You can use your health insurance whenever you go to an in-network doctor or Provider for a covered service. To find an in-network doctor, you can use our online Provider search tool.

What is the difference between in-network doctors and out-of-network doctors?

In-network doctors have a contract with Community to perform specific services for a pre-negotiated rate. These services are covered by your Community health plan. Out-of-network doctors do not have any sort of agreement with Community. You will be responsible for paying all costs for any visits to an out-of-network doctor or Provider.

Where can I go for care when my doctor’s office is closed?

If you need to see a doctor for care outside of their regular office hours, go to an in-network urgent care clinic or call the 24-hour nurse hotline for your plan.

What if I need to go to the doctor when I am out of town?

Community will cover any necessary emergency care if you are out of town. You will be responsible for paying all costs for any non-emergency care at out-of-network providers.

How do I know if a service is covered or not?

Your Summary of Benefits, Evidence of Coverage or the Member Service department can tell you whether or not a service is covered.

If I don’t use my health insurance, do I still have to pay for it?

Yes. Even if you don’t need to use your health insurance, you still need to pay your premium to stay covered.

What is a deductible?

A deductible is the amount you must pay for health care expenses before insurance covers any costs. If your plan has a deductible, it must be met each year before coverage begins.

For Members with Bronze deductible plans, Community offers three visits to a Primary Care Physician (PCP) at the plan’s copay cost before the deductible is met.

Where can I find out how much of my deductible I have paid?

You can find out how much of your deductible you’ve paid by using Community's Member portal.

Can other people use my insurance?

Only the persons covered under your policy and listed on your Member ID card can use your Community health plan.

A Guide to Insurance Terms

Premium

An amount to be paid for an insurance policy.

Copay

A fixed fee that you pay for health care services and products (such as doctor visits and pharmaceutical prescriptions).

Deductible

The amount you must pay for health care expenses before insurance covers the costs. Sometimes, a health insurance plan will have a yearly deductible that you must meet before coverage begins.

Coinsurance

The amount you must pay for health care expenses after your deductible has been met. Coinsurance amounts are shared amounts between the health insurance carrier and you. Your portion of the coinsurance is paid until your out-of-pocket maximum is met for the year. Example: Joe has insurance that pays 80% of medical expenses. Joe has a doctor visit. The visit cost is $100. Joe pays $20 (coinsurance amount) and his insurance pay $80.

Out-of-Pocket Maximum

This is the maximum amount you will pay out of your own pocket in a year for covered health care expenses. Typically, after your out-of-pocket maximum expense limit is met, the plan pays 100% of all covered services for the remainder of the year.

Enrollment Period

A specified period of time when you can enroll in an insurance plan.

In-Network Provider

A Provider who is contracted with the health plan to provide services to plan Members for specific, pre-negotiated rates.

Out-of-Network Provider

A Provider who is not contracted with the health plan.

Pre-existing Condition

A health care condition that existed before insurance coverage begins

Primary Care Provider

A health care professional (usually a physician) that is responsible for monitoring your overall health care needs.

Specialist

A health care professional who specializes in one area of medicine. For example, a cardiologist is a doctor who specializes in heart conditions.