A good way to have your health expenses covered at a reasonable cost is through health insurance. Increasing medical costs make finding good health insurance an important priority. The health insurance system is complex and constantly changing.
The following tips will help to answer some of the more common questions about health insurance and point you to other sources for more information.
1. How do I get health insurance?
Many people get group insurance through their employers as an employee benefit or through organizations to which they belong. The NC State Health Plan covers teachers, employees, retirees, and their eligible dependents. Individual insurance which may cover one person or several family members, is available for those who are self-employed or whose employers do not offer health insurance. If you don’t have health insurance through a job, Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or another source that provides qualifying coverage, see #5, information about the Affordable Care Act.
2. What kinds of health insurance policies are there?
Many people are covered under two types of major medical (or comprehensive) health insurance plans: traditional or managed care. Most major medical plans cover a broad range of medical expenses and usually require policyholders to pay out-of-pocket deductibles each plan year. A traditional plan allows patients to choose their own providers and pays claims based either on charges your doctor has agreed to in advance, or average charges for services provided in your area. Managed care plans try to manage the cost and quality of services for their members by requiring members to use a contracted network of providers, reviewing treatments and services before agreeing to pay, and limiting visits to specialists. HMO, HMO Point of Service and PPO are the three most common types of managed health care plans.
3. Are there other types of insurance I should know about?
Supplemental health insurance provides limited benefits for specific medical conditions and expenses. Dental, hospital indemnity, Medicare supplement, and specified accident are all types of supplemental insurance. The NC Department of Insurance publishes many Consumer Guides on Health Insurance, which cover Cancer, Disability, Managed Care, Medicare, and other topics.
NC Health Choice (NCHC) is a free or reduced price comprehensive health care program for children. NCHC may be helpful if your family makes too much money to qualify for Medicaid but too little to afford health insurance premiums.
4. What are Medicaid and Medicare?
Medicaid is a health insurance program for low-income parents, children, seniors, and people with disabilities. In North Carolina, Medicaid is jointly financed between federal, state, and county governments. To be eligible for Medicaid you must meet income requirements, be a U.S. citizen or be of eligible immigration status, live in North Carolina and have a social security card or have applied for one. Apply for Medicaid at the County Department of Social Services in the county where you live. For more information about Medicaid, see the NC Department of Health and Human Services Division of Medical Assistance site.
Medicare is a federal health insurance program for people 65 and older, certain people with disabilities, and people with end-stage renal disease. Medicare covers some costs of medical care including hospital and doctors’ charges, skilled nursing, home health, hospice, and outpatient care. For more information see: Questions about Medicare? For one-on-one help call the Seniors’ Health Insurance Information Program (SHIIP) at 855-408-1212. SHIIP uses trained volunteers to answer questions and offer free, unbiased counseling on Medicare products in every county in the state.
5. What is the Affordable Care Act?
The Affordable Care Act was passed by Congress and signed into law on March 23, 2010. On June 28, 2012, the Supreme Court rendered a final decision to uphold the health care law.
The Affordable Care Act (ACA) has ten sections:
- Title I. Quality, Affordable Health Care for All Americans
- Title II. The Role of Public Programs
- Title III. Improving the Quality and Efficiency of Health Care
- Title IV. Prevention of Chronic Disease and Improving Public Health
- Title V. Health Care Workforce
- Title VI. Transparency and Program Integrity
- Title VII. Improving Access to Innovative Medical Therapies
- Title VIII. Community Living Assistance Services and Supports Act (CLASS Act)
- Title IX. Revenue Provisions
- Title X. Reauthorization of the Indian Health Care Improvement Act
The provisions of the ACA are being phased in over four years. On October 1, 2013, open enrollment in the Health Insurance Marketplace began. For more information about the Affordable Care Act see Affordable Care Act Information, a site maintained by the State Library of North Carolina.
6. What should I consider when shopping for a plan?
Since insurance is a major purchase, it is a good idea to be sure you get the best value for your money. Determine what coverage options you need including amounts of insurance and deductibles as well as what price you are willing to pay. Consider whether your provider and hospital of choice participate in any plans that use provider networks. To make an informed decision, do some comparison shopping reviewing all quotations to determine if they are similar to each other. Ratings publications, consumer groups and magazines, and the Better Business Bureau are all good sources of information about insurance options.
7. How do I find a reputable insurance carrier?
Purchasing insurance can be time consuming and complicated; find an agent and insurance company you feel comfortable with and can rely on. You can check on the licensing status of insurance companies by calling the NCDOI Consumer Services Division at 855-408-1212. The licensing status of agents may be checked by using this License Lookup maintained by the NCDOI Agent Services Division.
8. What happens to my coverage if my job status changes?
Federal COBRA (Consolidated Omnibus Budget Reconciliation Act) law applies to employer groups covering 20 or more employees. You may continue your group policy coverage through COBRA for up to 18 months, and in some cases longer but you will be responsible for paying all of the premiums, including the share normally paid by your employer. For more information about COBRA, see the U.S. Department of Labor’s Employee Benefits Security Administration COBRA FAQ site. NC State Continuation laws also allow continued coverage under the employer’s group health plan for up to 18 months after eligibility is lost. For more information about the State Continuation call the NC DOI at 855-408-1212.
9. Who can I call if I have a question or complaint about health insurance?
You may call the Consumer Division of the NC Department of Insurance to speak with an insurance specialist about your questions. They can be reached at 855-408-1212 toll free. If you have a complaint, you may challenge decisions made by your health insurance company through an appeal and/or grievance process. Details about your plan’s grievance process should be included in your certificate of coverage and insurance policy. For more information about appeal and grievance provisions in NC law, call the Consumer Division at 855-408-1212 or consult their online guide.
10. Where can I find health care services for under or uninsured people?
The North Carolina Institute of Medicine maintains a web site that will help you find free and reduced cost health care services in your area. Visit nchealthcarehelp.org for assistance.
11. Need more information?
For more information about health insurance in North Carolina, see Health Insurance SmartNC on the NC Department of Insurance web site.
Page authored by Terri Ottosen, Health Sciences Library at UNC-Chapel Hill.