Frequently Asked Questions FAQ of NY Group & Company Health Insurance
Where can I find a list of network providers for my health insurance plan?
Your health insurance company may have a listing of network providers on its website, including links and phone numbers. Your health plan’s member services can also help you locate a network provider. Call the number on the back of your health insurance card.
Are all the providers at a network facility always network providers?
Not all healthcare professionals offering services at a network facility are network providers. For example, an anesthesiologist, pathologist, radiologist or an emergency room doctor working at a network hospital might be a non-network provider. If you see a non-network provider—even if you have no choice in the matter—the non-network provider’s services will be paid at the non-network benefit level.
What is a Health Savings Account (HSA)?
Associated with either the Health Investor HMO or PPO plans, this account allows you to use pretax dollars to pay your share of the cost for eligible health care expenses that are not covered by your health, dental or vision plans. Any unused HSA funds at the end of a year carry forward to the next year; you may also take unused HSA balances with you if you stop working for the state. When you are eligible for an HSA and have completed the necessary steps, the state makes a monthly contribution to your account (for active employees); you may also add your own contributions to your HSA.
I am currently insured under another group insurance plan, but I have accepted a position with the State of Florida. Will my pregnancy be considered a pre-existing condition under the State of Florida Group Health Insurance Program?
No. Under the Affordable Care Act, pre-existing condition limitations no longer apply.
What is the difference between HMOs, PPOs, and EPOs?
These health plans have different rules about seeing non-network providers. They also differ in whether or not they require that you have a primary care physician and whether or not you need a referral to see a specialist. For a more detailed explanation and a helpful video, see our PPO, EPO, and HMO page.
ACA plan benefits
Can you explain the requirements for pediatric dental coverage? I’ve read that it’s an essential health benefit that has to be covered on all plans, but I’m also hearing that it’s optional?
A: It depends. There is no penalty for not having pediatric dental on your policy. And in most exchanges, you can purchase a plan without pediatric dental. But off-exchange, carriers are required to include pediatric dental unless they have determined that you have pediatric dental from another source.
Pediatric dental coverage is one of the ten essential health benefits (EHBs) that the ACA has required on all individual and small group plans since 2014. But section 1302 of the ACA (see page 61) explains that a policy sold in an exchange without embedded pediatric dental coverage can still be a qualified health plan (QHP) as long as there is also a stand-alone pediatric dental plan available in the exchange.
Exchanges must offer pediatric dental, either via coverage that is embedded in the medical plans, or in separate stand-alone plans. But in most states, enrollees are not required to have pediatric dental coverage if they buy a health plan through the exchange, even if there are children on the policy, as long as there are stand-alone pediatric dental plans available for purchase. They can simply purchase a QHP that does not have pediatric dental and will have satisfied the ACA’s individual mandate.
Most states leave it up to the insurers to determine whether to embed pediatric dental coverage. There are some exceptions, though. For example, Washington State exchange enrollees are required to purchase pediatric dental coverage; Covered California began requiring all health plans sold through the exchange to have embedded pediatric dental coverage starting in 2015; Connecticut’s exchange required embedded pediatric dental coverage on all plans starting in 2014.
I’ve read that pediatric dental is one of the essential health benefits on new plans. Does that mean that my insurance will cover braces for my son?
Pediatric dental is one of the essential health benefits, although it’s a bit more complicated than the other nine. Some medical policies have pediatric dental embedded in the plan, while plans in many states rely on separate stand-alone pediatric dental policies that supplement an enrollee’s medical coverage. But in general, orthodontia is only covered if it is deemed medically necessary, and the regulations vary from one state to another.
Utah opted to require its pediatric dental plans to cover only preventive care, as the benchmark plan on which Utah’s exchange plans are based does not cover restorative dental care. But the rest of the states have more comprehensive pediatric dental plans, and most include at least some degree of coverage for medically necessary orthodontia. The American Dental Association noted in late 2017, however, that three other states — Arkansas, Colorado, and Michigan — have benchmark plans that don’t include any coverage for medically necessary orthodontia.
HHS left it up to the states to define “medically necessary” but the definition tends to range from narrow to very narrow. In some cases, orthodontics are covered if the child’s dental malocclusion is significant enough to cause problems with eating or speaking. In other cases, orthodontia is only covered if it is to treat congenital defects such as cleft palate or hemifacial microsomia, or following corrective jaw surgery.
Non-medically necessary orthodontia (sometimes called “cosmetic orthodontia”) is generally not covered on individual market pediatric dental plans (it’s not uncommon, however, for employer-sponsored plans to provide at least partial coverage for cosmetic orthodontia). Check with your state division of insurance and the pediatric dental carriers in your state to see what’s required and what is offered as far as orthodontia coverage. And be sure to seek prior authorization if you are planning to use a pediatric dental plan to cover medically necessary orthodontia.
How is vision care covered under the Affordable Care Act?
The Affordable Care Act requires coverage for pediatric vision care as one of the essential health benefits. So for children under the age of 19, vision coverage is included in all new individual market plans (with effective dates of January 2014 or later), on and off-exchange. This means kids have coverage for eye exams, vision screening, and glasses or contact lenses to correct vision problems.
Vision screening for children falls under the category of preventive care, which means it’s covered at no charge until kids turn 19 (as long as you have an ACA-compliant plan). But vision screening is not the same thing as an eye exam. Vision screening can be performed by a pediatrician or family physician to identify or detect vision difficulties. The screening may not diagnose the child’s condition, but it can indicate whether the screening should be followed up with a comprehensive exam.
Although pediatric vision care beyond vision screening is covered under the ACA, everything other than vision screening can have copays, or be counted towards the deductible and/or covered with coinsurance. Some carriers do offer free eye exams and glasses for kids though – it depends on the carrier, so read the fine print on the plans you’re considering.
Do all health insurance plans cover maternity?
Large-group plans have long been required to include maternity coverage, thanks to the Pregnancy Discrimination Act of 1978, which applies to employers with 15 or more employees. In addition, 18 states had passed laws over the years that required smaller groups and/or individual policies to cover maternity benefits.
Some states had tighter requirements even before the ACA, but the ACA closed the remaining gaps. The ACA requires large employers (50 or more employees) to offer coverage to their full-time employees, and the longstanding Pregnancy Discrimination Act ensures that maternity care is part of the coverage. The ACA also requires all individual and small group plans to include maternity care as one of the law’s essential health benefits. Small employers (up to 49 employees) are not required to offer coverage, but if they do, it has to include maternity care.
And anyone who doesn’t have access to coverage from an employer can purchase an individual market plan instead, with coverage for maternity care included in all plans in every state. Maternity coverage must be covered on all non-grandfathered/grandmothered individual and small group plans issued or renewed after January 1, 2014. So all of the policies being sold in the exchanges — and off-exchange — include maternity coverage. The ACA also prohibits gender-based premium determination, so women cannot be charged more for their policies than men.
Prior to 2014, the majority of individual health insurance policies did not cover maternity as a standard benefit. In some states, it was available as an optional rider, but the cost was often prohibitively high, since the coverage was usually only purchased by people who were planning to use it, and was priced accordingly.
The ACA also prohibits health plans from turning away applicants because of preexisting conditions, including pregnancy. Prior to 2014, pregnant women (and expectant fathers) in most states could not obtain coverage in the individual market, even if the plan didn’t include any maternity benefits.
Do ACA-compliant health insurance plans cover abortion?
Some do, and some don’t. They are not required to, and in more than half the states, plans sold in the exchange are not allowed to cover abortions except for circumstances involving rape, incest, or the mother’s life being in danger.
The ACA makes a delineation between abortions for which federal funding cannot be used, versus those for which it can. This was clarified by President Obama in Executive Order 13535, and is very similar to the longstanding Hyde Amendment that dates back to 1976.
The ACA and Executive Order 13535 are clear in stating that federal funding (including premium subsidies and cost-sharing subsidies) cannot be used to pay for abortions, unless the mother’s life is in danger or the pregnancy is the result of rape or incest. Abortions that don’t fall within those three exceptions are generally called “non-excepted” or “elective” or “non-Hyde.”
Starting with 2019 plans, HealthCare.gov displays information on whether or not each plan provides elective abortion coverage (ie, abortion coverage for circumstances other than rape, incest, or to protect the mother’s life).
How is autism covered under health plans sold in the health insurance marketplaces or under the ACA?
According to the U.S. Centers for Disease Control, one in every 88 children in the United States has autism. In recent years more and more states have begun mandating coverage by health plans for services in the treatment of autism.
By 2015, a total of 41 states and the District of Columbia had enacted some level of autism coverage insurance mandates, and 29 states have enacted regulations that require autism coverage to be included on all plans sold through the exchange. But the specifics in the mandates vary significantly from one state to another.
Some apply only to individual health policies, while others include small group and large corporate policies (no state mandates apply to the self-insured policies large employers typically offer, which is the type of coverage one-quarter of insured Americans have). The mandates also vary in terms of what types of treatment are required to be covered.
Under the Affordable Care Act, autism screening is now covered under preventive care with zero cost share for children at 18 and 24 months. This screening takes place during well-child visits. Screening without cost-sharing may be especially important for the early detection and diagnosis of autism.
Are visits to the chiropractor or physical therapist covered under the Affordable Care Act?
All ACA-compliant individual and small group plans include coverage for physical therapy. Some individual market plans, sold via the health insurance marketplacesand off-exchange, include coverage for chiropractic services – but many do not. It depends in large part on where you live, as different states have different rules.
Does the ACA require infertility treatment to be covered by health insurance?
No. Treatment for infertility is not one of the ten essential benefits, and coverage for it is not mandated by the ACA or any other federal law. But that doesn’t mean it’s never covered, as states can have regulations that go beyond the minimum requirements laid out by the federal government.