Shopping for a Health Plan

Make a list of the physicians, labs, hospitals, and other health care providers you use to ensure they'll be covered under the health plan. Using a non-participating provider may lead to health care services not being covered and a larger financial responsibility.  Keep in mind the following when choosing a health plan:

• Can you keep your current provider(s)?

• Does the health plan require the designation of a primary care physician from their provider network or can you choose your own?

• If you need to choose a new provider, are there in-network providers accepting new patients?

• Does the plan require referrals for specialists?

• Does the plan require prior authorization for certain services?

• Does the plan have providers, pharmacies, and hospitals near your home or work?

• If you travel frequently or if your dependents live outside of the plan’s service area, is out-of-network coverage provided?

• If you choose an out-of-network provider, will the health plan pay any portion of the cost?

Contacting the insurer when there is a benefit question or concern is also a factor to take into consideration when shopping for coverage.

• How long does it take to reach a customer service representative?

• Can the insurer be contacted via email or online chat?

• Does the insurer receive a significant number of consumer complaints? You can view an insurer’s complaint statistics on DIFS' website. NOTE: DIFS does not rate or recommend health insurers.

Health insurance may be purchased during the annual open enrollment period or through a special enrollment period in the following ways:

• Health Insurance Marketplace: An application may be completed online at www.healthcare.gov or by calling 800-318-2596.
• Directly from a health insurance company: DIFS provides a list of authorized health insurance companies and Health Maintenance Organizations (HMOs), and the areas in which they offer coverage at www.michigan.gov/DIFS.
• Through your or your spouse's employer: Some employers offer health coverage as an employee benefit.
• Through a college or university you attend: Some higher learning institutions offer coverage to their students.
• Through Medicare or Medicaid, for those who qualify: For Medicare, call 800-663-4227 or visit www.medicare.gov. For Medicaid, call Michigan Enrolls at 800-975-7630 or visit www.michigan.gov/mibridges.

For questions or help with purchasing health insurance, you can seek the assistance of:

• A federally trained navigator or certified application counselor: Trained individuals can provide enrollment assistance for Marketplace plans. To find Marketplace assistance in your area, visit localhelp.healthcare.gov.
• A licensed agent: To find licensed health insurance agents in your area and to verify their licensure in Michigan, use DIFS' Insurance Licensee Locator.

Individual health coverage is only available to purchase during the annual open enrollment period unless you qualify for a special enrollment period.

During open enrollment, individuals can shop for coverage in the Marketplace or outside of the Marketplace. Insurance purchased through the Marketplace may qualify applicants for additional savings, such as an advanced premium tax credit or a cost-sharing reduction. To access the Marketplace or to learn more, visit www.healthcare.gov or call the Marketplace at 800-318-2596.

Some insurers and agents can sell you plans through the Marketplace. These insurers and agents must sign agreements with the Marketplace to sell Marketplace-qualified health plans. Find assistance at https://localhelp.healthcare.gov.

SEPs are a time outside the annual open enrollment period when you may qualify to purchase or change your health insurance. The following events may qualify you for a SEP:

• Loss of qualifying health coverage (i.e., a group health plan or Medicaid)

• Change in household size (i.e., marriage/divorce, new baby, or adoption)

• Moving

• Other situations

You have 60 days from the date your health plan ended to enroll in a new plan through a SEP. You may be required to provide proof that you are eligible for a SEP, such as a birth or marriage certificate or proof of new residency.

To learn more, visit www.healthcare.gov or call the Marketplace at 800-318-2596. You may also contact an insurer or licensed agent with more questions.

• No Denials for Pre-Existing Conditions.  An insurer cannot deny coverage, charge more, or impose a waiting period for a health plan because of a pre-existing condition.

• Ban on Health Plan Rescissions. Insurers are prohibited from rescinding or retroactively canceling a health plan unless fraud has been committed or there is an intentional misrepresentation of an important fact on the insurance application.

• No Lifetime Dollar Limits on Your Health Care Costs. Health insurers are prohibited from setting lifetime dollar limits on significant benefits, such as hospitalization and emergency services. The ACA also eliminates the annual dollar limits a health plan can place on most of your benefits.

• Extended Coverage to Dependents. Most health insurers and employers providing dependent coverage must make coverage available to age 26.  Dependents are permitted to stay on their parent’s coverage even if the dependent:

  • Is eligible for a health plan from their own job.

  • Is no longer a student.

  • Is not financially dependent on their parents.

  • Can no longer be claimed as a tax dependent.

  • Gets married.

  • Lives separately from their parents.

  • Has a child of their own.

Several private firms specialize in evaluating the finances and services of insurance companies or health maintenance organizations. Each of these agencies has its own methods and standards and gives grades to the companies based on their judgment of how well the company is doing.

Contact information for some of the most popular rating firms is listed below. There may be a charge for some reports. Several of these rating firms publish books with their ratings, so you may also be able to find what you need at your local library. Before you rely on any report, make sure you understand the rating system because each firm has its own grading system. For example, one firm may use "A+" as its top grade, while another may go all the way up to "A+++."

A.M. Best Company
Phone: 908-439-2200
Website: www.ambest.com

Fitch Ratings
Phone: 888-262-4820
Website: www.fitchratings.com

Moody's Investor Service
Phone: 212-553-1653
Website: www.moodys.com

Standard & Poor's
Phone: 877-772-5436, option 4
Website: www.standardandpoors.com

Links to health insurer complaint information:

• Health Insurance companies

Links to health insurer financial information:

• Health Insurance Companies Financial Information
• HMO Financial Information