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Being Heard: Health Insurance

Updated: Dec 6, 2021

If you ever had to deal with health insurance customer service, you have my sincerest condolences. Health insurance companies are one of those weird little bloodsucking parasites, that also seem to be protected by Federal Law. In case you're not sure what I'm talking about, you should read up on the Affordable Care Act (ACA). Generally speaking, these companies will do the bare minimum for their customer, while still doing what's best for their bottom line. I have had the genuine misfortune in the past trying to ensure my wife gets the most basic prenatal coverage for our unborn child, and I have to tell you, it was worse than pulling teeth.

Sure, you can have affordable health care. Just jump through these hoops first.

Why am I writing all of this? Because I want to make sure that whoever is thinking about submitting an appeal or formal complaint against a denied claim doesn't waste too much time and effort on a wild goose chase. We will briefly go over things to consider when trying to get out of a crappy health insurance plan.

As I mentioned earlier, health insurance companies are protected under the Affordable Care Act (ACA), with a couple of caveats. They must, at the very least provide the following:

  1. Minimum essential coverage (MEC)

  2. Affordability

  3. Minimum Value (if insurance plan is provided by employer)

There are a couple of criteria which determine whether your plan qualifies as having MEC, however, one of the easiest resources you can check your plan is to go to the government marketplace website. Generally, with few exceptions, most plans fall under this category. We will list the exceptions as follows:

  1. Limited-Benefit Plans

  2. Critical Illness Plans

  3. Accident Supplements

  4. Dental/Vision Plans

As can be clearly seen above, it doesn't take very much at all to qualify as MEC, making it hard to get out of a plan once you are locked in. But what about affordability? Once again, the Government Marketplace website is a good place to check. The link I provided has a link that can be used to determine whether health insurance plan is considered affordable. If this is not the case, you may qualify to disenroll from your current plan and seek better options.

Aside from that, your only other option is to put up with your health insurance until Open Enrollment comes along and you can choose to opt out of your health insurance plan if you're unhappy with it. Either that, or you can disenroll at any time if you have a Special Qualifying Event. These can basically be summarized as follows:

  1. Involuntary Loss of Coverage

  2. Individual Plan Renewing Outside of Open Enrollment

  3. Becoming or gaining dependent(s)

  4. Marriage

  5. Divorce

  6. Becoming a US Citizen

  7. Permanent moves

  8. Enrollment clerical error

  9. Employer plan is not affordable or provides MEC

  10. Income change that moves you out of coverage gap

  11. Gaining access to Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) or Individual Coverage HRA

  12. Income or changes that makes you newly eligible for cost-sharing reductions (CSR)

Finally, we will talk about what minimum value is. If you are receiving health insurance from your employer, there is a bare minimum that their health insurances must provide in order for it to be considered lawful. Basically, a plan is considered to have minimum value if the insurer is able to cover at least 60% of the medical costs, within a 50 mile radius. If you are interested in reading further, refer to IRS notice 2014-69. And, that's basically it. If you feel cheated at all by the way your company or your health insurance plan is treating you, unfortunately, as long as they cover the bare minimum, it is considered lawful. The bare minimum is not necessarily good for a lot of people, but it is what it is. Next time, we will discuss how to appeal claims and submit claims against your health insurance.

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