Understanding Health Insurance Options
Insurance is one of those things that you hope you’ll never need. But even those who are young and in good health occasionally need to visit the doctor. And in the case of a major illness or accident, the cost of care can quickly become unaffordable. Buying health insurance makes it easier to afford some of those costs and helps protect you from expenses growing too high.
When you buy a plan, an insurance company agrees to pay some of those expenses involved when you get sick or hurt. Some plans include dental coverage and prescription drug coverage in addition to medical coverage, but you should always ask to make sure. The bottom line is that having a health insurance plan is part of leading a healthy and independent life. And now it’s also the law.
Young people who are entering adulthood should ask themselves: How am I going to be insured? Below are some explanations of how insurance works and some options available.
How Health Insurance Coverage Works
This explanation comes from HealthCare.gov, the federal government’s health insurance program through the Affordable Care Act.
When you have insurance, you pay some costs and your insurance plan pays some others. Here are some of the ways that the payments break down:
- Premium. A premium is a fixed amount you pay to your insurance plan, usually every month. You pay this even if you don’t use medical care that month.
- Deductible. If you need medical care, a deductible is the amount you pay for care before the insurance company starts to pay its share. Once you meet your deductible, your insurance company begins to cover some costs of your care. Some plans have lower deductibles, like $250. Some have higher deductibles, like $2,000. Many plans provide preventive services, and sometimes other care, before you’ve met your deductible.
- Copayment. A copayment is a fixed amount you’ll pay for a medical service after you’ve met your deductible. For example, after meeting your deductible, you may pay $25 for a visit to the doctor’s office that would cost $150 if you didn’t have coverage. The health plan pays the rest.
- Coinsurance. Coinsurance is similar to a copayment, except it’s a percentage of costs you pay. For instance, you may pay 20 percent of the cost of a $100 medical bill. So you would pay $20, and the health plan would pay the rest.
If you don’t have health coverage at all, you have to pay the full cost of all of your medical expenses. You also have no protection from very high bills. In addition, because the Affordable Care Act requires everyone to buy health insurance, if you don’t have health coverage in 2014 and beyond, you may have to pay a fee.
Understanding the Health Care System
Most health insurance plans have moved toward a managed care system. This simply meant that hospitals, doctors, pharmacies and other providers participate in health networks designed to lower costs. For example, TennCare provides its services through regional MCOs (or managed care organizations).
Private insurance plans provide services through a similar system, such as an HMO (health maintenance organization) or a PPO (preferred provider organization).
- HMOs require patients to see providers only within a specific network. The only exception to this may be emergency medical care.
- PPOs also maintain a list of preferred providers. Patients do have the option of going outside the network, but will pay higher out-of-pocket expenses for that choice.
For an explanation of other insurance terms, HealthCare.gov provides a helpful glossary.
Know Your Options
Remember, young adults have several options when it comes to health insurance, including:
- Enrolling in an employer-sponsored health insurance plan
- Remaining on your parents’ health insurance plan through age 26
- Purchasing individual coverage through the federal Health Insurance Marketplace
- Purchasing individual coverage through a private insurance company or MCO (Note: These plans may not cover pre-existing medical conditions.)
- Enrolling in state Medicaid coverage through TennCare (if eligible), which means applying through the Health Insurance Marketplace (Read more on this below.)
If you need insurance, start by filling out an application for the federal Health Insurance Marketplace at the ACA website, and you will be notified whether you qualify for private health insurance, Medicaid or lower-cost options.
To learn more about the Affordable Care Act, visit HealthCare.gov or call 800-318-2596.
What About TennCare?
TennCare is the state of Tennessee’s Medicaid program, which provides health insurance to mostly low-income pregnant women, parents or caretakers of a minor child, children and individuals who are elderly or have a disability. For more information about eligibility for TennCare and covered services, visit their website. You can also call the Tennessee Health Connection Call Center at 855-259-0701 from 7 a.m. to 7 p.m. CST if you have questions about your eligibility or to see if you qualify.
When an Individual Turns 26
On their 26th birthday, a child who was on their parents’ plan loses coverage. At that point, they qualify for a Special Enrollment Period. This lets them enroll in a health plan outside of Open Enrollment, which is a set period once a year during which people can sign up for a plan.
Important things to know when an individual turns 26 and loses coverage from their parents' plan:
- They may qualify for tax credits and other savings based on their income.
- They can enroll up to 60 days before their 26th birthday. Their Special Enrollment Period ends 60 days after their birthday.
- If they enroll before their birthday, coverage can start as soon as the first day of the month they lose coverage. If they enroll during the 60 days after their birthday, coverage can start the first day of the month after picking a plan.
- If they don’t enroll in health coverage within 60 days of their birthday, they may not be able to get coverage until the next Open Enrollment period.
- If they aren’t insured, they may have to pay the fee that some uninsured people pay. If they’re uncovered for less than three months of the calendar year, they don't have to pay the fee.
TennCare for Youth who Aged-out of Foster Care
Did you age out of Foster Care in Tennessee, or are about to? Are you between the ages of 18 and 26?
If so, you may qualify for insurance through the Affordable Care Act.
Youth who aged out of foster care are able to receive TennCare coverage until they are 26-years-old under the Affordable Care Act, which went into effect January 1, 2014.
You are eligible for full insurance benefits, including:
- Screening, prevention and early intervention services
- Diagnostic services and treatment for physical and mental health conditions
Am I covered?
- If you aged out, or are about to age out, of foster care, as long as you continue to live in Tennessee, you will be automatically approved for TennCare insurance in the Former Foster Care category. You may be contacted by TennCare for verifications. If you have moved from Tennessee, and returned, you will need to reapply through healthcare.gov.
- If you aged out of foster care before Jan. 1, 2014, and are receiving Extension of Foster Care Services you should contact your DCS case manager or TennCare to verify your status.
- If you aged out of foster care prior to Jan. 1, 2014 and were not receiving Extension of Foster Care Services, did not reapply for TennCare, or were denied, you need to apply through the health insurance marketplace, healthcare.gov.
- If you left state custody as an adult who was not enrolled in TennCare, such as youth who were in a Youth Development Center, you need to apply for health insurance through the marketplace, healthcare.gov.
How do I Apply?
To apply, visit healthcare.gov. If you do not have a computer or internet access, go to a local DHS office and apply at a kiosk.
If you think you may be eligible, call your Regional DCS office and talk to the Health Care Advocacy Representative. If you already have TennCare coverage, you can call the Tennessee Health Connection at 1-855-259-0701.
You must apply for TennCare through the Health Insurance Marketplace. You can still use a paper application, but you also can apply online or by phone through the Health Insurance Marketplace, healthcare.gov. Or, you can call 1-800-318-2596. After the Health Insurance Marketplace reviews your application, they’ll tell us if you are eligible for TennCare.
Call the Tennessee Health Connection toll-free at 855-259-0701 7 a.m. to 7 p.m. CST Monday to Saturday. For the Tennessee Relay Service (TNRS) call 800-848-0298, give them 855-259-0701 and choose option 4.
Need More Information?
You can call the DCS Independent Living Staff toll free, Call DCS toll free, 844-887-7277