Health Insurance Basics

How long are my children covered under my plan?

We continue coverage of the child until the date they get group health insurance from their own job or through the family plan’s anniversary date once they turn 26. At the point of plan renewal, the now-age-26 child could buy a policy on his/her own, but no longer will be eligible for coverage under the family plan.

Is my dependent covered if they live in another state?

Yes, if your dependents live full-time, or attend college in another state, they will have the same coverage as if they were living with you.

What is dependent care?

Dependent care is insurance coverage for family members of a health insurance policyholder, such as spouses, children or partners.

What are emergency services?

Emergency services are the evaluation of an emergency medical condition and treatment to keep the condition from getting worse. True emergencies, such as heart attacks or serious accidents, are life-threatening situations that should be treated in a hospital emergency room.

What is emergency care?

Emergency care is any treatment you receive in response to a serious medical condition such as an illness, injury, symptom or condition that requires you to seek care right away.

What is emergency medical transportation?

Emergency medical transportation is ambulance services for an emergency medical condition.

What is emergency room care?

Emergency room care is the service and treatment you receive in an emergency room.

Can I use a provider that is not in my plan network?

In some cases you can use a provider that is not in the plan network. Check your plan description or contact HealthyCT to find out. Be aware that if you use a provider who is not in the plan network, the services may cost you more, and in some cases may not be covered.

Do I need to choose a primary care doctor before my coverage begins?

No, you can select a doctor at any time after you are enrolled in the plan.

How can I find out if my doctor is in a HealthyCT plan?

To find out if your doctor is in a HealthyCT plan, use our doctor search tool.

What do I do if my doctor is not in a HealthyCT plan?

Recommend your doctor to join our HealthyCT network. They can contact us, or get started in the Provider section of the HCT website.

What is a health care provider?

A health care provider is a person or organization licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.

What is a Primary Care Provider (PCP)?

A doctor, nurse practitioner, clinical nurse specialist or physician assistant chosen by you, as allowed under state law, who provides, or helps a patient get health care services. Typically, this physician is trained to treat a wide variety of health-related problems, and will refer you to specialists when needed.

What is a referral?

A referral is a written order from your primary care doctor for you to see a specialist or get certain medical services. In some cases, if you don’t get a referral first, the plan may not pay for the services.

What is the difference between in-network providers and out-of-network providers?

An in-network provider is a doctor, hospital or other health care provider who has a contract with HealthyCT. Your costs may be less when you use an in-network provider.

What are preventive services?

Preventive services are activities to prevent illness such as immunizations, patient counseling and screenings. Most of these services are offered at no cost to you. Refer to your plan documents for more information on exactly what services are covered or see this document for a list of preventive services covered under the Affordable Care Act.

What is Health and Wellness care?

Health and Wellness care are programs intended to improve and promote health and fitness. For example, programs to help you stop smoking, diabetes management programs, weight loss programs and preventive health screenings.

Can I change from one plan to another?

You can change plans during an enrollment period. You can also change plans if you have what is called a Qualifying Life Event, like moving, finding a new job, getting married or divorced.

How long am I covered?

Plan coverage usually lasts one year. Before the year is over, there will be another enrollment period. You can decide to keep your plan for another year, or chose a different plan.

How much will I have to pay for my health insurance?

The amount you pay for health insurance depends on the plan you choose. If you choose a plan with a low premium, you’ll pay more of your medical costs yourself. If you choose a plan that has a higher premium, your insurance will cost more, but it will pay for a bigger portion of your medical expenses.

What are excluded services?

Excluded services are healthcare services that your health insurance plan doesn’t pay for or cover. Your plan’s Certificate of Coverage explains what your insurance does and doesn’t cover.

What if I can’t afford to pay for health care insurance?

Depending on your income, you may be able to get money from the federal government to help pay for health insurance. To qualify for subsidies you need to enroll in a plan at Connecticut’s new health insurance marketplace called Access Health CT. See if you qualify!

What is a copay?

A copay is a fixed amount (for example, $15) that you pay for covered healthcare services like office visits or prescriptions. Your copay costs depend on what HealthyCT plan you choose.

What is a deductible?

The amount you must pay for health care services before your plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you have paid $1,000 in health care costs. In some cases, the deductible doesn’t apply to all services. For example, a plan could have a deductible for hospital services, but not for doctor’s visits.

What is a Health Savings Account?

Health Savings Accounts (HSA) are tax-deductible savings plans that let you save pre-tax dollars for future healthcare expenses not covered by your plan. You can take out money from a HSA to pay for most medical expenses. A HSA can’t be used with all insurance plans. Check your plan for more information.

What is a pre-existing condition?

A pre-existing condition is a health problem you had before your new health coverage starts. Under the Affordable Care Act, you can’t be denied coverage because you have a pre-existing condition.

What is a premium?

A premium is the amount of money you pay for your health insurance. You can pay this amount monthly.

What is a qualifying event?

A qualifying event is a change in your life that allows you to enroll in health coverage after an enrollment period has closed. For example, moving to a new state, change in income, or changes in your family size (for example, if you marry or divorce).

What is a quote?

A quote gives you an idea of what your health care insurance will cost, based on the plan you pick. You can get quotes for several insurance plans at once so you can compare the benefits and prices for each.

What is a Schedule of Benefits?

A Schedule of Benefits is a list of what your insurance plan does and doesn’t cover. However, it doesn’t include everything. For plan details, see your Certificate of Coverage. To view a Schedule of Benefits and Certificate of Coverage for your plan, visit your plan’s detail page.

What is an effective date?

An effective date is the date your healthcare coverage starts.

What is an enrollment period?

An enrollment period is the time when you can sign up for healthcare insurance. You may also sign up during special enrollment periods outside of open enrollment if you have a qualifying event, like moving, finding a new job, getting married or divorced.

What is care coordination?

You may need to see more than one doctor and visit different healthcare centers, this is when you might need and get a HealthyCT Care Coordinator.  Care coordination keeps your different healthcare services organized.

What is coinsurance?

Coinsurance is your share of the cost for a covered healthcare service. It is a percentage of the total reimbursement. For example, if your coinsurance is 30% and the service costs $100; your coinsurance is $30.

What is covered under my health insurance plan?

In general, your health insurance plan covers doctor visits, medical tests, hospital stays, outpatient procedures and prescriptions. See your plan’s details to find out exactly what is covered and how the cost is shared between HealthyCT and you.

What is dependent coverage?

Dependent coverage is insurance coverage for family members, like spouses, children or partners.

What is healthcare insurance?

Health care insurance is a contract between you and a health insurance company. The health insurance company pays some or all of your healthcare costs, and you pay the insurance company a fixed amount, called a premium.

What is preauthorization?

Sometimes your doctor needs to tell your insurance company about treatments you might need to make sure they’re covered by your plan and are medically necessary. This is called preauthorization. In order for your plan to cover some or all of the cost, these types of services must receive Prior Authorization before you have them.

What is the Affordable Care Act (ACA)?

The Affordable Care Act is a 2010 U.S. law aimed at reducing healthcare costs and making health insurance more affordable.

What kinds of healthcare insurance plans does HealthyCT offer?

HealthyCT offers a range of health insurance plans. We have plans for individuals and families with different healthcare needs. See our plans and descriptions.

Can I have my prescriptions delivered to my home?

Yes, prescription drugs that are covered by your benefit plan are available through mail order. Refer to your plan details to find out how to set up prescription delivery options.

What are generic drugs?

A generic drug is a prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. Most generic drugs are Tier 1 drugs.

What are non-preferred drugs?

Non-preferred drugs are more expensive drugs used to treat a medical condition. Non-preferred drugs are Tier 3 drugs.

What are preferred drugs?

Preferred drugs are brand name drugs that are generally less expensive than other drugs that used to treat the same condition. Preferred drugs are Tier 2 drugs.

What are specialty medicines?

Specialty medicines are high cost prescription drugs used to treat complex chronic conditions, such as cancer, rheumatoid arthritis, and multiple sclerosis. They can require special storage, handling and administration.  Specialty drugs often involve a significant degree of patient education, and monitoring. Depending on the benefit, Specialty drugs may be found in various copay/coinsurance tiers, or they may be found in their own unique Tier. Prescriptions for Specialty drugs are available through our Specialty pharmacy, BriovaRx.

What is a Formulary?

A Formulary is a list of prescription drugs covered by a prescription drug plan.

What is a prescription deductible?

A prescription deductible is the amount that you have to pay for prescription drugs before your health insurance begins to pay for some or all of the cost.

What is a Tier?

A Tier is a grouping of drugs; there is a different cost for each group. Generally, a drug in a higher tier will cost you more than a drug in a lower tier. There are four tiers: Generic drugs are Tier 1. Preferred brand name drugs are Tier 2. Non-preferred drugs are Tier 3 and specialty medicines are Tier 4.

What is prescription copay?

A Prescription Copay is a fixed amount (for example, $10) that you pay for a prescription. This amount can be different depending on which HealthyCT plan you are enrolled in. See your plan description for the copay amount in your health care plan.