Health Care Coverage Guide
Health Insurance | 20 Jun 2022
A comprehensive health insurance guide on how to get affordable health insurance in Kansas, help with marketplace insurance, and health insurance navigator resources.
Finding health insurance can seem complicated, but this health insurance guide can make things much simpler. This comprehensive health care insurance guide covers how to get health insurance, what the health insurance marketplace is, how to get help with marketplace insurance with a health insurance navigator, how to navigate healthcare.gov, various health insurance plans, health insurance comparisons, and tips to find affordable health insurance.
Cover Kansas is a free resource for all Kansans to learn about how to get health insurance and work directly with a health insurance navigator near you to get covered — all for free!
HEALTH INSURANCE GUIDE TABLE OF CONTENTS:
- How to get Health Insurance
- Health Insurance Plan Costs
- Types of Health Insurance Plans
- What Do Health Plans Cover
- Health Insurance Disputes
- Health Care Rights
- Buying and Choosing a Health Care Plan
- Losing Your Health Insurance
- Get Help with Buying Health Insurance Plans
How Do I Get Health Insurance?
Getting sick can be expensive. Even minor illnesses and injuries can cost thousands of dollars to diagnose and treat. Major illnesses can cost many times that. Health care coverage helps you get the care you need and protects you and your family financially if you get sick or injured.
If you are asking how to get health insurance, the main ways you can get it is…
- Through your job, if your employer offers it.
- Through a government program such as Medicare or Medicaid (including CHIP).
- Buying it through a membership association, union, or church.
- Buying it from an insurance company or agent.
- Buying it through the federal health insurance marketplace.
Group Insurance
Insurance you get through your job or an association is called “Group Insurance.” You must be a member of the group to get coverage. Some people get health insurance through their job, but not all employers offer it.
Individual Insurance
Insurance you buy directly from a company or the marketplace is called “Individual Insurance” because it’s sold to individuals, not to a group. There are 123 total plans available for 2022. See the 2022 Kansas Insurance Plans Brief (PDF) for a list of companies and health maintenance organizations (HMOs) that sell individual health insurance in Kansas.
To buy through the marketplace, you can visit HealthCare.gov, get free help from a Certified Navigator, or call our toll-free number: (866) 826-8375.
You must meet eligibility requirements for government health care programs. For more information about government programs, visit Benefits.gov or check out our FAQ page.
How Do I Get Insurance For My Family?
You can add your family to a work health plan if your health insurance comes from your job. If you buy from an insurance company or the marketplace, you can buy a plan that also covers your family.
You can keep your dependent children on your health insurance plan until they turn 26. They don’t have to live at home, be enrolled in school, or be claimed as a dependent on your tax return. You can keep married children on your plan, but you can’t add their spouses or children to it.
If you have dependent grandchildren, you can keep them on your plan until they turn 25.
When Can I Enroll in Health Care Insurance?
You usually must buy a plan during the open enrollment period. However, certain life events can qualify you for a special enrollment period at any time of the year.
The open enrollment period for marketplace and individual plans is from November 1 to December 15 each year. You can buy at other times only if you lose your coverage or have a qualifying life change. Life changes include things like getting married or divorced, having a baby, or adopting a child.
If you are getting health insurance through your job, you can sign up for a work health plan when you’re first hired or have a major life change. You have 31 days to decide whether you want to join the plan. You might have to wait up to 90 days for your coverage to start. If you join your work plan, you must wait until the next open enrollment period if you decide to drop out or change your coverage. The open enrollment period for work plans might be different from the marketplace period.
Can I Be Turned Down For Health Insurance?
You can’t be turned down if you have a preexisting condition.
Insurance companies must sell to anyone who applies during the open enrollment period. They can’t deny you coverage or charge you more because of a preexisting condition or disability.
Cost of Health Plans
The cost of health care insurance depends on your circumstances. You’ll have to pay premiums and part of the cost of your care. A premium is a monthly fee you pay to have coverage. To decide your premium, insurance companies will consider:
- Your age.
- Where you live.
- Whether you smoke or use tobacco.
- Whether the coverage is for one person or a family.
Health care insurance providers may not consider your gender or health factors, including your medical history or whether you have a disability.
Premiums for individual plans are locked in for one year. Rates usually go up when the plan is renewed to reflect your age and higher health care costs. Federal law requires companies to justify rate increases of 10% or more.
If you get health insurance at work, the insurance company will base premiums on the whole group. You might have to pay more if you use tobacco. Your employer might pay all or some of your premiums. If you include your family on your health plan, your employer usually won’t pay their premiums.
Premium Tax Credits Can Help You Pay For Coverage
A premium tax credit is a refundable tax credit from the IRS designed to help eligible individuals and families with low or moderate income afford health insurance purchased through the Health Insurance Marketplace, also known as the Exchange. The size of your premium tax credit is based on a sliding scale.
Tax credits are amounts taken off what you owe in taxes, and you can use these savings to pay your health insurance premiums. To get a tax credit, you must buy through the federal marketplace. Your income must be between 100% and 400% of the federal poverty level.
You can’t get a tax credit if your employer offers affordable health insurance or your income is below the poverty level.
You and your health plan share the cost of your care
All health insurance plans require you to pay some of the cost of your health care. This is called “cost-sharing.” In addition to premiums, you usually must meet a deductible, pay copayments, and pay coinsurance.
- A deductible is the amount you must pay before your plan will pay. For example, if your deductible is $500, your plan won’t pay anything until you’ve paid $500 yourself. You’ll have to meet a deductible each year. Some plans have more than one deductible. For instance, you might have one deductible for in-network care and another for out-of-network care. If your plan covers your family, you’ll have a separate deductible for each family member and a deductible for the family. Some plans don’t have deductibles.
- Copayments are fees you pay each time you get a covered health service. For example, you might have to pay $25 when you go to the doctor and $15 when you fill a prescription. You’ll also have a copayment if you go to the emergency room or see a specialist. The amounts vary by plan.
- Coinsurance is an amount you pay for a covered service after you’ve met your deductible. It’s usually a percentage of the cost of the service. For example, your health plan might pay 80 % of the cost of a surgery or hospital stay. You pay the other 20%. The percentage you pay in coinsurance varies by plan. You usually don’t have to pay coinsurance in an HMO.
Federal law sets limits on the amount you pay out of pocket in a plan year. Some health insurance plans have lower out-of-pocket limits. After you reach the limit, you don’t have to pay copayments or coinsurance for the rest of the plan year. You still have to pay premiums, though. A plan year is the 12-month period from the date your coverage started. For instance, if your coverage started on February 1, your plan year lasts until January 31 the following year.
Types of Health Care Insurance Plans
There are four types of major medical health plans in Kansas (IF THIS NEEDS EDITED PLEASE CHANGE). Major medical plans cover a broad range of health care services. The four types are:
- HMO plans
- Exclusive Provider (EPO) plans
- Preferred Provider (PPO) plans
- Point-of-Service plans
All four types are managed care plans. This means they contract with doctors and other health care providers to treat their members at discounted rates. These providers make up a plan’s network. Managed-care plans limit your choice of doctors or encourage you to use doctors in their networks. In return, you pay less out of pocket for your care. The health insurance plans differ in the extent to which you can use doctors outside the network and whether you must have a doctor to oversee your care.
The Health Insurance Marketplace (also known as the “Marketplace” or “Exchange”) provides health plan shopping and enrollment services through websites, call centers, and in-person help.
Cover Kansas has a vast network of health care navigators across the state of Kansas and virtual navigators to help Kansans get enrolled in the marketplace.
HMO Plans
You must use providers in the HMO’s network. If you don’t, you might have to pay the full cost of your care yourself. There are exceptions for emergencies and if you need care that isn’t available in the network.
You must choose a doctor to oversee your health care. This doctor is called your primary care physician. You usually must get a referral from your primary care physician to go to a specialist. Women don’t need a referral to go to an OB/GYN if the doctor is in the HMO’s network. Under some circumstances, you can use a specialist as your primary care physician. To do this, you must have an ongoing, disabling or life-threatening condition.
EPO Plans
With Exclusive Provider plans (EPO) you must use providers in the network of the insurance organization. If you don’t, you might have to pay the full cost of your care. There are exceptions for emergencies and if you need care that isn’t available in the network.
EPO plans usually don’t require you to have a primary care physician. You also don’t need a referral to go to a specialist.
PPO Plans
With a Preferred Provider plan (PPO) you can go to any doctor you choose, but your out-of-pocket costs will be lower if you use doctors in the PPO’s network. You don’t have to choose a primary care physician, and you don’t need a referral to go to a specialist.
Point-of-Service Plans
Like PPO plans, point-of-service plans let you go to any doctor you choose. But your out-of-pocket costs will be lower if you use doctors in the plan’s network. You usually must have a primary care physician and get referrals to specialists. Women don’t need a referral to go to an OB/GYN.
How Health Plans Compare
| Question | HMO | EPO | PPO | Point-of-service |
| What’s the cost? | Generally lowest of all plans | Usually lower than PPO | Generally highest of all plans | Usually lower than PPO |
| Do I have to use providers in the network? | Yes (except for emergencies and for care that isn’t available in network) | Yes (except for emergencies and for care that isn’t available in network) | No (but you’ll have to pay more if you go out of network) | No (but you’ll have to pay more if you go out of network) |
| Do I have to choose a primary care physician? | Yes | No | No | Usually |
| Do I need a referral to a specialist? | Yes | No | No | Usually |
Other Types of Coverage
There are other types of health insurance that provide only limited coverage. Companies selling them can deny you coverage or charge you more if you have a preexisting condition. They also usually limit the amount they will pay for your care.
- Specified disease policies pay only if you have the illness named in the policy. For instance, a cancer policy will pay only if you have cancer. It won’t pay if you have another disease.
- Short-term policies provide coverage for only a limited time, usually six to 12 months. People sometimes buy these policies while they’re between jobs or waiting for other coverage to start.
What Health Plans Cover
Coverages vary by plan. Coverage requirements are different for plans you get at work and those you buy directly from an insurance company. Even among plans you get at work, the requirements are different depending on whether you work for a small employer or a large one. If you ask, your plan must give you a Summary of Benefits and Coverages.
Federal law requires individual and small-employer plans to cover 10 types of health care services, called essential health benefits. In addition, Kansas requires some plans to include certain health benefits. Some plans might cover more services, like adult dental and vision care and weight management programs.
Preventive Services Must be Provided for Free
Federal law requires health plans to cover many preventive services at no cost to you. You might be able to get free check-ups, blood pressure and diabetes testing, contraceptives, mammograms, cancer screenings, and flu shots. Visit HealthCare.gov’s Preventive Health Services page to see the full list of free services. You must go to a doctor in your network to get the free services.
You Might Need Approval For Some Services
Most plans require you to get approval before some covered services. For instance, you might need approval before having surgery or going into the hospital. Check with your plan to find out whether you need approval. If you don’t get approval, the plan might not pay.
Resolving Disputes About Your Health Plan
The insurance company should send you an explanation of benefits form that states how much the insurer paid or why it denied the claim. Call the insurer if you don’t understand the explanation or disagree with a decision your health plan made. Many wrongful claim denials stem from coding errors, missing information, oversights, or misunderstandings.
You can appeal a decision, file a complaint, or ask for an external review of your case by working directly with your health insurance provider.
- Gather necessary documents from your healthcare provider and request a letter of medical necessity that outlines why the recommended treatment you received was medically necessary.
- In cases in which you’re denied because the service or treatment you received wasn’t covered, provide peer-reviewed medical studies to support your case that the service was medically necessary. If you initially got a second opinion and the provider recommended the same treatment, use it as evidence for your appeal.
- Write a health insurance appeal letter to your health care insurance provider. Include your address, name, insurance identification number, date of birth for the person whose claim was denied, date the services were provided, and the health insurance claim number.
- The first sentence of your appeal should state that you are appealing the claim denial, and the body of the letter should explain why the medical bills should be paid. Include details on what you’re appealing and why you feel your claim should be paid. Put in a closing sentence demanding payment, and include supporting documentation.
- Appeals should be based on the reason something has been denied. Stick to the facts, use your supporting evidence, don’t inject emotional outbursts into your letter, and state the specific outcome that you expect to come as a result of the appeal.
Filing a Complaint
If you believe you have been discriminated against, your rights have been violated, or the wrong decision was made, you have options.
- Step 1: Identify a health insurance issue.
- Step 2: Collect necessary information.
- Step 3: Exhaust other appeals options.
- Step 4: Determine where to file the complaint.
- Step 5: File the complaint.
Find out how to file a complaint or appeal a decision related to health information privacy, civil rights, Medicare, and more on the HHS Complaints and Appeals page.
Surprise Medical Bills
Patients might get “surprise” medical bills if they get care outside their health plan’s network without realizing it. For example, if you need surgery you will probably pick a surgeon in your plan’s network. But you may not be asked to pick the anesthesiologist. If the anesthesiologist is out of your health plan’s network, you will get a “surprise bill.”
This is also known as “balance billing.” State and federal laws protect you from surprise medical bills.
Your Rights
- Companies can’t put dollar limits on your care.
Insurance companies can’t stop paying your claims just because they’ve already paid a certain amount for your health care. - Your policy can’t be rescinded.
Insurance companies can’t rescind your policy if you unintentionally made a mistake on your application for insurance. Companies may rescind a policy only if you commit fraud or lied on your application. Rescind means to cancel a policy back to the start date as if you’d never had coverage. - Coverage renewals are guaranteed.
Most individual health plans are guaranteed renewable. This means your insurance company can’t cancel your policy if you get sick. - Plans must have adequate networks.
Kansas law requires HMOs, PPOs, and EPOs to make covered services available within a certain distance of your home or office. Health plans also must:- Have enough providers to meet the needs of their members.
- Let you keep going to your doctor for a period of time after your doctor leaves the network. To do this, you must have a terminal illness, disability, life-threatening condition, or be pregnant. The doctor must agree to continue treating you at the plan’s contract rate.
- Pay for care to stabilize your condition after an emergency. If you get emergency care at a facility outside your network, you may be transferred to a network hospital when your condition is stable.
- Pay for care outside your network if you need care that’s not available in the network.
- Employers must have an open enrollment period each year.
If your employer offers a health plan, the employer must have a 31-day open enrollment period each year. You can use this period to join the plan if you didn’t earlier. You can also use it to drop or change your coverage.
Shopping For a Health Plan
- Know what you’ll have to pay.
Plans with higher deductibles, copayments, and coinsurance have lower premiums. But you’ll have to pay more out of pocket when you get care. - Consider things other than cost.
To learn a company’s financial rating and complaints history, call our Help Line or visit our website. - Get help.
If you buy health insurance from the federal marketplace, you can get free help choosing a plan. You can visit HealthCare.gov, get free help from a Certified Navigator, or contact us at our toll-free number: (866) 826-8375. - Buy only from licensed companies and agents.
If you buy from an unlicensed insurance company, your claim could go unpaid if the company goes broke. Call our Help Line or visit our website to check whether a company or agent has a license. - Get several quotes and compare coverages.
Know what each plan covers. If you have doctors you want to keep, make sure they’re in the plan’s network. If they’re not, you might have to change doctors. Also make sure your medications are on the plan’s list of approved drugs. A plan won’t pay for drugs that aren’t on its list. - Fill out your application accurately and completely.
If you provide false information or leave something out on purpose, an insurance company may cancel your coverage or refuse to pay your claims.
Cover Kansas is a free resource for all Kansans to learn about how to get health insurance and work directly with a health insurance navigator near you to get covered — all for free! Visit our Find A Navigator page to get started or call us toll-free at (866) 826-8375 and our insurance specialists can help with any insurance questions you may have.
Finding Doctors That Accept Plans
Call your insurance company or state Medicaid and CHIP program. Look at their website or check your member handbook to find doctors in your network who take your health coverage. Ask your friends or family if they have doctors they like and use this tool to compare doctors and other health care providers in your area.
Our free health navigators can help you when picking a plan to ensure your doctor or provider is in network.
Losing Your Plan
If you or a member of your household loses health insurance, a special enrollment period that extends 60 days from the loss of the job and health insurance will allow you to buy an ACA policy at HealthCare.gov. Our free health care navigators can help you get coverage.
Reasons you might lose health coverage include:
- If you leave your job…
- You can usually continue your coverage temporarily under COBRA (the Consolidated Omnibus Budget Reconciliation Act).
- If a company stops offering your plan…
- Insurance companies may decide to stop offering a plan. If your company drops your plan, it must offer you another plan it sells. If it doesn’t sell any other plans, you’ll have to shop for new coverage.
- Your company can no longer pay its claims…
- Guaranty associations pay claims for licensed insurance companies that go broke. There are separate guaranty associations for different lines of insurance. It will pay claims up to a dollar limit set by law.
- It doesn’t pay claims for HMOs and some other types of plans. If an HMO can’t pay its claims, the commissioner of insurance can assign the HMO’s members to another HMO in the area.
What is COBRA?
COBRA is a federal law that lets employees continue their health coverage for a period of time after they leave their job. It applies to coverage from employers with 20 or more employees. It doesn’t apply to plans offered by the federal government or some church-related groups.
You can get COBRA coverage if:
- You leave your job for any reason other than gross misconduct. Gross misconduct usually means doing something harmful to others, reckless, or illegal.
- You lose your coverage at work because you switch from working full-time to part-time.
If your family was on your health plan, you can continue their coverage under COBRA. Your spouse and children also can continue their coverage if you go on Medicare, you and your spouse divorce, or you die. They must have been on your plan for one year or be younger than 1 year old. Their coverage will end if they get other coverage, don’t pay the premiums, or your employer stops offering health insurance.
You have 60 days after you leave your job to decide whether you want COBRA. You must tell your employer in writing that you want it. If you continue your coverage under COBRA, you must pay the premiums yourself. Your employer doesn’t have to pay any of your premiums.
Your COBRA coverage will be the same as the coverage you had with your employer’s plan. If you continue HMO coverage and move out of the service area, the HMO will pay only for emergency care. COBRA coverage will end if your employer stops offering health insurance.
You Can Keep Your Plan Longer With State Continuation
Kansas law requires some group plans to continue your coverage for six months after COBRA coverage ends. The maximum period of continuation coverage under Kansas law is 18 months. Your plan must be subject to Kansas insurance laws. State continuation doesn’t apply to self-funded plans since the state doesn’t regulate them.
State continuation lets you keep your coverage even if you can’t get COBRA. If you aren’t eligible for COBRA, you can continue your coverage with state continuation for nine months after your job ends. To get state continuation, you must have had coverage for the three months before your job ended.
You usually can’t get state continuation if you were fired.
How Long You Can Keep Your Plan
| If you’re getting COBRA and you’re … | You can continue a plan through COBRA for … | You can continue a plan through state continuation for an extra … |
| The employee | 18 months | 6 months |
| The employee’s spouse, ex-spouse, or dependent child | 36 months | 6 months |
| If you can’t get COBRA and you’re … | You can continue a plan through COBRA for … | You can continue a plan through state continuation for an extra … |
| Primary or secondary plan member | 0 months | 9 months |
Note: If you have a disability, you can get coverage for an additional 11 months after COBRA coverage ends. The Social Security Administration determines disability. Your employer must tell you about continuation of coverage within 30 days from the date your job ended.
Programs That Can Help
These programs and organizations provide various health care services, information, and affordable health insurance options. Some services might be free or low-cost.
Cover Kansas
Cover Kansas is a free resource for all Kansans to learn about how to get health insurance and work directly with a health insurance navigator near you to get covered — all for free!
Useful links from Cover Kansas:
- Find A Healthcare Navigator
- Special Enrollment Periods
- Financial Assistance
- How-To Videos
- Spanish Resources
Healthcare.gov
HealthCare.gov is a health insurance exchange website operated by the United States federal government under the provisions of the Affordable Care Act or ACA, commonly referred to as “Obamacare”, which currently serves the residents of the U.S. states which have opted not to create their own state exchanges.
Useful links from Healthcare.gov:
- Picking a Plan
- Are You Eligible to Use the Marketplace?
- Medicaid and CHIP coverage
- Dental Coverage in the Marketplace
- Marketplace Appeals
Marketplace.CMS.gov
The official Marketplace information source for assisters and outreach partners. On this site, you’ll find information about assister programs and tools to help existing and new Health Insurance Marketplace consumers.
Useful links from Marketplace.CMS.gov:
- Payments, Grace Periods and Terminations
- Application for Families (PDF)
- Application for Individuals
- Protect Yourself from Fraud
- Medicare and the Health Insurance Marketplace
Insurance.Kansas.gov
The mission of The Kansas Insurance Department is to regulate and review companies that sell policies in Kansas to ensure solvency and compliance with insurance and securities laws and regulations. Educate consumers about all things insurance and securities by publishing brochures and rate guides to assist in the shopping process, giving presentations to groups across Kansas and serving as a non-biased source of information. Advocate for a strong and competitive market to give Kansans choices when shopping for products that meet their needs.
Useful links from The Kansas Insurance Department:
KanCare
KanCare is the program through which the State of Kansas administers Medicaid. Launched in January, 2013, KanCare is delivering whole-person, integrated care to more than 415,000 people across the state.
Useful links from KanCare:
Sunflower Health Plan
Sunflower Health Plan offers Kansas health insurance plans. Their plans are called Kansas Medicaid, Ambetter from Sunflower Health Plan, and Wellcare By Allwell from Sunflower Health Plan.
Useful links from Sunflower Health Plan:
UnitedHealthcare
UnitedHealthcare offers Kansas health insurance plans. Their plans are called UnitedHealthcare Community Plan KanCare, UnitedHealthcare Medicare, and Medicaid.
Useful links from UnitedHealthcare:
Kansas Department of Health and Environment (KDHE)
The Kansas Department of Health and Environment is a state agency in Kansas, responsible for the state’s public health system, medical records, and environmental sustainability.
Useful links from KDHE:
- Medicaid & CHIP
- Public Health Services Guide
- Community Health Systems
- Find Local Health Department (PDF)
Community Care Network of Kansas
Community Care Network of Kansas is the federally designated Primary Care Association (PCA) for Kansas. Community Care Network is comprised of health centers and community-based clinics with a common goal of providing high-quality healthcare that is accessible to all Kansans.
Useful links from Community Care Network:
