Insurance Overview & Oversight

In this section we cover:

Insurance Overview

Health insurance is provided by a patchwork of public and private sources in the U.S. Woman reading about medical insurance on a laptopThe majority of Americans with health coverage—about two-thirds—have private health insurance, with over half of them getting insurance through an employer. The remainder of those with health coverage get insurance through pubic programs such as Medicare, Medicaid, TRICARE or the VA. According to the U.S. Census Bureau, in 2018, 8.5% of Americans, or 27.5 million, did not have health insurance.

The Patient Protection and Affordable Care Act (ACA) contains key provisions and services that most private insurance plans must provide. Importantly, the ACA:

  • Bans the practice of charging more or denying health insurance coverage due to a pre-existing health condition
  • Prohibits health plans from putting annual or lifetime dollar limits on most benefits
  • Requires coverage of certain essential health benefits and preventive services with no out-of-pocket costs to the patient and more

Visit the Laws & Protections section of our website for comprehensive information about the ACA.

Public health programs like Medicare and Medicaid, as well as self-funded, grandfathered and short-term private health plans are not required to abide by all of the ACA rules. For more specifics, visit healthcare.gov.

Insurance Oversight

If you have private individual or group health insurance and believe that your legal rights under the Affordable Care Act have been violated, you should contact the health insurer first to understand its coverage decision. If the issue cannot be resolved directly with the insurer, the next step is to contact your state insurance commissioner's office. Finally, you can contact the Health Insurance Hotline at the Center for Consumer Information and Insurance Oversight (CCIIO) at Health Insurance Hotline at (410) 786-1565 or email: phig@cms.hhs.gov.

Visit the Medicare website or call 1-800-MEDICARE (1-800-633-4227) to learn more about what Medicare covers and how to manage claims and appeals.

Each state manages its Medicaid program independently. Contact your state program if you have questions or concerns about Medicaid eligibility, benefits or coverage.

paying-for-service

 

  • If your insurance company denies coverage of recommended medical services, visit the Health Insurance Appeals section of our website for guidance and resources.