FAIR Health Consumer Access

Help with Insurance Issues

Sometimes you may need help dealing with health insurance issues. You might have questions about what your insurance will cover, or need support in finding and enrolling in a plan. Or you may have claim issues with your insurance company. For instance, the company may pay less than you expected for a service, or say it won’t cover a service at all. There are many places you can find help for all of these concerns.

Help Finding and Enrolling in a Plan
If you need help choosing and enrolling in a healthcare plan, a number of different people and organizations can help you. These include navigators, certified application counselors (CACs), agents and brokers.

Navigators are people or organizations that can help you to find healthcare through the Health Insurance Marketplace (also called the Health Insurance Exchange). Navigators aren’t allowed to suggest one plan over another. Their services are free.

CACs are like navigators, but their focus is on helping people to enroll in a plan. They may be linked with local groups called certified application counselor designated organizations (CDOs). CDOs can be health centers, faith-based groups, colleges or other types of organizations. Like navigators, CACs don’t charge fees for their services.

Agents and brokers who are certified by the Health Insurance Marketplace can help you to understand the different plans you can join, just like navigators and CACs. But they can also recommend plans, based on your situation. They’ll also help you after you’ve enrolled in a plan. Agents and brokers are similar, but brokers may represent more companies or offer different types of insurance than agents.

Most agents and brokers don’t charge for their services. However, in some states and in certain cases, they’re allowed to charge you a fee. If they do, they’re required to tell you up front, before they’ve performed any services for you.

You can find a navigator, CAC, agent or broker at Find Local Help, a search tool run by the federal government. Find Local Help lets you find a navigator, CAC, agent or broker in your local area who is trained to help you choose and sign up for health insurance plans.

Help with Insurance Claim Issues
Your health insurance company may pay less than you expected for a service. Or the company may say it won’t pay for the service at all. This is called denying the claim. If this happens to you, there are steps you can take and places where you can find help.

The First Step
A good first step is to talk to your insurance company and find out why the payment was denied or why you received less reimbursement than you expected. Sometimes it turns out that a simple mistake was made. For example, the wrong medical code may have been used for the claim, or you may have misunderstood the level of payment reflected in your plan document when seeking services. But there may have been other reasons for your particular concern, like your insurer didn’t think the service was medically necessary. In that case, you may want to file an appeal with your insurance company. Read our article “If Your Plan Doesn’t Pay (Appealing a Reimbursement Decision)” to learn more.

Nonprofit Resources
If you or your family member has been diagnosed with a chronic, serious or life-threatening illness, the Patient Advocate Foundation (PAF) may be able to help you. The PAF is a nonprofit group that can assign you a case manager to help resolve insurance problems and other issues related to care. There is no charge for case manager services through the PAF.

State Resources
Many states have a Consumer Assistance Program (CAP). CAPs can help you to understand your rights, file an appeal if your insurance company won’t pay for a service or file a complaint about the company. Whether or not your state has a CAP, you still have rights and protections under federal healthcare law. You can find out more about those protections here.

Click here to link to your state’s CAP. There you can also find other helpful resources, such as your state’s Department of Insurance, with which you can file a complaint about your health plan. You can discover more state resources on our State Resources page.

Private Patient Advocates
Private patient advocates are also called claims assistance professionals. They don’t work for the state or federal government. They may come from backgrounds as nurses, medical office managers, billing specialists, lawyers or other jobs that involve handling medical bills.

Private patient advocates can help you with claims that have been denied by your insurance company or with reimbursements that are less than you expected. They can also file appeals and get approval from your insurance company for medical care.

Private patient advocates may charge you a flat fee or by the hour. Their services can be expensive. However, many employers will cover the cost of private advocate services. Also, some private patient advocates will charge you only if they save you money. Be sure to ask if this is the case when you contact a professional advocate.

The Alliance of Claims Assistance Professionals (ACAP) is a nonprofit organization that can put you in touch with a private patient advocate. Click here to find a private claims assistance professional through the ACAP site.