FAQ (Frequently Asked Questions)


Getting Insurance | Surprise Billing | Copay Accumulator Program



Getting Insurance

  • How do I choose a plan based on a pre-existing diagnosis?
    • If you are choosing a plan through the individual family plan market, the Affordable Care Act guarantees coverage for patients with pre-existing conditions.
    • However, if you are purchasing an individual or small group plan outside of the Exchange, or enrolling in a plan through your employer it is important to check the plan documents, such as the Summary of Benefits and Coverage (SBC) or the Evidence of Coverage (EOCT) to see what may or may not be covered. Off-Exchange plans and some employer based plans are not required to follow the Affordable Care Act laws.
  • What do I do about insurance if travelling internationally or studying abroad?
    • Make sure to discuss with your healthcare team where you will be travelling to be certain that your vaccinations are up to date.
    • Plan ahead! It may be possible to receive medications when travelling abroad.
  • I’m changing my insurance plan this year. What should I do next?
    • Review the details of your new insurance plan to make sure your needed medications and services will be adequately covered under the new plan.
    • Notify your physician’s office as new insurances typically require a re-authorization of certain medications even if you have been on it long-term. If this re-authorization is not done in a timely way, this can result in missed doses.
  • What should I do if I have a gap or lapse in insurance?

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Surprise Billing

  • What is surprise billing and balance billing?
    • Surprise balance billing refers to a patient being billed for the full cost of a service when an out-of-network physicians provides care at an in-network facility.
    • As of January 2022, patients have new billing protections when receiving emergency care, non-emergency care from out-of-network physicians at in-network facilities, and air ambulance services from out-of-network physicians.
    • These new rules help to protect patients from excessive out-of-pocket costs and require emergency services to be covered without prior authorization, regardless of whether a provider is in network. In many cases, the out-of-network physician or provider bills patients the difference between the charges and the amount covered by your insurance plan. This process is known as balance billing.

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Copay Accumulator Program

  • What should I do if I think I may have a copay accumulator program?
    • First connect with your insurer and ask questions – especially if you’ve been unable to fill your prescription. If you are employed and receive the insurance through your employer – tell them. They may have chosen this plan thinking it was a cost-savings strategy without understanding the negative impact it could have on employees.  Click here to learn more about copay accumulator programs.