The Affordable Care Act (ACA) is a law enacted in 2010 to ensure all Americans have access to health insurance. The ACA offers more health insurance options, discounts and broader Medicaid coverage to people who may not have been able to afford it. If you don’t have health insurance under the ACA, you have to pay a penalty.
If you don’t have health coverage, you may have to pay a fee. The fee is calculated 2 different ways – as a percentage of your household income, and per person. You’ll pay whichever is higher. The fee rises with inflation.
Percentage of income
Maximum: Total yearly premium for the national average price of a Bronze plan sold through the Marketplace
If your employer offers health insurance, the Affordable Care Act shouldn’t affect you. If you pay for your own insurance, it means you can now shop for plans on a health insurance marketplace or exchange to compare rates.
A health insurance exchange is a place where people who don’t have coverage can shop for health insurance plans. Exchanges differ by state, and what you pay will depend on your income. You can buy insurance on the exchange during an open enrollment period each year.
Individual and family open enrollment for 2018 begins November 1, 2017 and ends December 15, 2017. If you miss the enrollment window, you may still be able to get health insurance if you have a qualifying life event including a birth or adoption, marriage, divorce, permanent move to a new state, involuntary loss of coverage or if you become a U.S. citizen.
By law, all health insurance exchange plans for individuals and families must cover:
To be eligible, you must be a U.S. citizen or lawfully present in the U.S., live in the state where your exchange is (for CHRISTUS Health Plan that’s Texas or New Mexico), and not be currently incarcerated.
If you meet certain requirements, you may qualify for a tax credit or cost-sharing reduction. To qualify for either a tax credit or cost-sharing reduction, you must purchase your health insurance through healthcare.gov. As part of the application process, the government website will tell you whether or not you qualify for a tax credit or cost-sharing reduction.
You can use a tax credit to make advance payments that lower your monthly premium costs. If the amount of advance payments you make for the year is less than your tax credit, you’ll get the difference as a refundable credit when you file your federal income tax return. If the amount of advance payments you make for the year is more than your tax credit, you must repay the excess advance payments with your tax return.
The reduction is a discount that lowers the amount of your deductibles, coinsurance and copayments. You get this reduction if you get health insurance through healthcare.gov, your income is below a certain level, and you choose a health plan from the Silver plan category.
Health plans on the exchange are labeled platinum, gold, silver or bronze based on the level of coverage they offer. Platinum plans mean you pay less for medical services but have a higher monthly premium. A bronze plan offers the lowest monthly premium, but you will pay more for medical services.
A deductible is the amount you must pay before your health insurance kicks in. This amount varies by plan level. Coinsurance is usually how health care costs are split with your insurance after your deductible is met. These percentages also vary by plan. A copayment is what you pay for a service when you receive it, like a doctor’s office visit or getting a prescription filled. All of these things add up to your total out-of-pocket cost for health insurance, which is capped at a certain amount for the year. After you meet the max out-of-pocket, your insurance will cover 100% of expenses.
If you can’t afford health insurance, you may qualify for Medicaid, cost assistance or health insurance credits. If you are pregnant or have children, you may be eligible for a CHIP plan, designed for families who earn too much for Medicaid but still can’t afford insurance.
If you disagree with a decision on your coverage or payment, you can file an appeal to review the decision. If you’re unhappy with service, you can file a grievance (or a complaint). Learn more about appeals and grievances.
CHRISTUS Health Plan
Attn: Appeal and Grievance Dept.
PO Box 169009
Irving, TX 75016
Appeals must be made in writing, but you can make a grievance by calling 1-844-282-0380.
If your drug is not included in the formulary (list of covered drugs), you should call Member Services at 1-844-282-3025, 5 days a week, 8 a.m. to 5 p.m. local time. You can double-check if the drug is covered, and if it’s not, you have two options:
You can ask CHRISTUS Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber submits his or her supporting statement to the Plan for review.
For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request. If CHRISTUS Health Plan coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal/redetermination with the Plan.
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.
You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
Once it has been identified that you need an exception for a drug that is not on the formulary, Member Services will help you with the next steps to request an exception. For more detailed information about your CHRISTUS Health Plan prescription drug coverage, please review your plan forms and documents.
Members of CHRISTUS Health Plan have the opportunity to share feedback with us! If you would like to be a part of the CHRISTUS Health Plan New Mexico Member Advisory Board, please let us know. You can tell us you are interested by calling Member Services at 1-844-282-3025.
To participate in the Member Advisory Board, you must be
· A current enrollee of a health plan offered in New Mexico;
· An employee of a group that subscribes to the health plan; or
· A representative of a consumer organization that represents the interests of health care consumers. No member of the health plan’s consumer advisory board shall be an employee of the health plan or its affiliates, or an immediate family member of a health plan employee.
The Member Advisory Board meets quarterly and serves to advise the health plan about general operations from the member perspective. We will review the Member Advisory Board recommendations at the health plan Quality Improvement Committee. After review, the CHRISTUS Health Plan Chief Executive Officer will respond to the Member Advisory Board regarding the recommendations.
MM161 & MM162
Last Updated: 2/23/17