Montana Health Insurance Frequently Asked Questions (FAQs)

Below is a list of Montana health insurance frequently asked questions, from who is required to have a plan to how to enroll. This is by no means an exhaustive list. If you have any other questions, or if you want to talk to a local person about your options, contact an enrollment assister today!

What is the Health Insurance Marketplace?
The Health Insurance Marketplace (also known as the Exchange) is a place to purchase health insurance from a competitive marketplace using The Health Insurance Marketplace offers a choice of different health plans and provides information to help consumers better understand their options. Premium and cost-sharing subsidies are only available through the Marketplace to reduce the cost of coverage for individuals and families, based on their income. The insurance sold through is offered by private insurance companies. The plans are identical to what the companies sell outside the website.

Who can buy coverage in the Marketplace?
Most people can shop for coverage in the Marketplace. To be eligible you must be a citizen of the U.S. or be lawfully present in the U.S. You must also not currently be incarcerated. However, not everybody who is eligible to purchase coverage in the Marketplace will be eligible for subsidies. To qualify for subsidies (also called premium tax credits) you will have to meet additional requirements regarding you income and your eligibility for other coverage.

I’m uninsured. Do I have to get health insurance?
Unless you qualify for an exemption, everyone is required to have “minimum essential coverage” or else pay a tax penalty. This requirement is called the individual responsibility requirement or the individual mandate.

When can I enroll in Medicaid through the Marketplace?
You can enroll in Medicaid or Healthy Montana Kids (HMK) at any time during the year, not just during Open Enrollment.

Can I buy or change private health plan coverage outside of open enrollment?
Most people chose and purchase their plan during open enrollment and keep it for the year, but if you wish to switch plans or buy a new health plan, you must have a special enrollment opportunity (SEP) to sign up for private, non-group coverage during the year. These are the events that trigger a special enrollment opportunity.

How long after I enroll in a plan will coverage take effect?
If you enroll between the 1st and 15th day of the month and pay your premium by the due date, your coverage will begin on the first day of the next month. If you enroll on January 10, 2015, your coverage will begin on February 1, 2015.

If you enroll between the 16th and the last day of the month and pay your premium by the due date, your effective date of coverage will be the first day of the second following month. If you enroll on January 16, 2015, your coverage Will start on March 1, 2015.

What health plans are offered through the Marketplace?
All health plans offered through the Marketplace must meet the requirements of “qualified health plans.” This means that they cover essential health benefits, limit the amount of cost sharing (such as deductibles and co-pays) for covered benefits, and satisfy all other consumer protections required under the Affordable Care Act. The Marketplace is the only place to apply for premium and cost sharing subsidies.

The benefits of each health plan vary. Health plans also vary based on the level of cost sharing required. Plans are labeled Bronze, Silver, Gold, and Platinum to indicate the overall amount of required cost sharing. Bronze plans have the highest deductibles and other cost sharing, while Platinum plans have the lowest. Health plans also vary based on the networks of hospitals and other health care providers that they offer. Some plans require you to get all non-emergency care in-network, while others provide some coverage when you receive out-of-network care.

How do I find out if my doctor is part of my health plan’s network?
Each plan sold in the Marketplace must provide a link on the Marketplace website to a health provider directory. This directory allows consumers to find out if their health providers are included. Your plan’s informational pamphlets should also include this information.

What happens if I need care from a doctor who is not part of my health insurance network?
Plans are not required to cover any care received from a non-network provider, though many plans today do, to some extent. If you receive out-of-network care, it could be costly to you. Non-network providers are also not contracted to limit their charges to an amount the insurer says is reasonable, so you might also owe “balance billing” expenses. If extenuating circumstances require that you receive services from a doctor who is not part of your health insurance network, you can request coverage from your health insurance company. Help is available through the Commissioner of Securities and Insurance Office.

How can I find out if a plan covers the prescription medication that I take?
Health plans in the Marketplace must include a link to their prescription drug “formulary” as well as other online information about the plan. The “formulary” is a list of prescription drugs that the plan covers. If you don’t find your drug on the formulary but your doctor says it’s medically necessary for you to take that specific drug, you can appeal for an exception to the plan formulary. Once you have a health plan, you can always call your insurance company to find out if your medication is covered.

Can I be charged more if I have a preexisting condition?
No. As of 2014, health plans are not allowed to charge you more based on your health status or a pre-existing condition.

I signed up for a health plan at the beginning of Open Enrollment but then changed my mind. Can I change plans as long as Open Enrollment is still open?
Yes. You can switch to a different plan at any time during Open Enrollment.

What do I need to enroll?
Whether you’re enrolling online, over the phone, or in person, there is certain information you’ll need to have available:

To enroll in Medicaid or CHIP you’ll need:

  • Names, dates of birth, and Social Security numbers for all those applying.
  • Pay stubs from the last 3 months for anyone working in your household.
  • Information about health insurance offered through you or your spouse’s job (if applicable).

To enroll in the Health Insurance Marketplace you’ll need:

  • Names, dates of birth, and Social Security Numbers for all those applying.
  • Estimated annual household income (to see if you qualify for a discount).
  • Information about health insurance offered through you or your spouse’s job.

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