Navigator Guide FAQs of the Week: Will My Plan Deliver the Care I Need?


The deadline to enroll in coverage starting January 1 has passed in most states, but thanks to this year’s open enrollment extension, you still have time to secure your health coverage for 2022 on HealthCare.gov. In addition to affordability, a plan’s provider network and prescription drug coverage are important considerations for consumers when choosing a plan. As part of CHIR’s weekly series highlighting FAQs from our updated Navigator Resource Guide, we discuss how to make sure your plan provides access to the doctors, prescription drugs, and culturally competent care that you need.

How can I find out if my doctor is in a health plan’s network?

Each plan sold in the marketplace must provide a link on the marketplace website to its health provider directory so consumers can find out if their health providers are included. Health plans are also required to keep their provider lists up to date. A doctor look-up tool is available on HealthCare.gov so that consumers can determine whether or not a doctor is included in a health plan’s network. However, as an extra measure, you may want to call the plan directly as well as your provider to confirm that he or she is “in-network.”

The provider network information from insurance companies must also tell you whether a provider is accepting new patients.

How can I find out if a health plan covers the prescription drugs that I take?

Health plans in the marketplace must include a link to their prescription drug “formulary” (a list of covered drugs) with other on-line information about prescription drug coverage such as tiering structures and whether any restrictions exist to accessing covered drugs. The formulary should be easily accessible, meaning that it can be viewed on the health plan’s public web site through a clearly identifiable link or tab without creating an account or entering a policy number. The health plan must provide the formulary for the health plan and not a general list for the insurer. 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 apply for an exception to the plan formulary. A prescription look up tool is also available on HealthCare.gov for consumers to determine whether or not a health plan covers a prescription drug.

I am interested in making sure my plan includes a provider who is culturally competent. Do provider networks list the race/ethnicity of the provider or their experience with certain communities?

Provider directories do not have to include information about the race/ethnicity of the provider or specific expertise in working with particular communities. Some provider networks, however, voluntarily include this information. If you are interested in finding providers in your network who are from or who have experience working with certain communities, looking to national and state provider networks hosted by professional medical associations may be helpful (for example, Gay and Lesbian Medical Association, BlackDoctor.org, and Trans Health).

As the COVID-19 pandemic persists into the new year, enrolling in a health insurance plan that allows you to access the care you need when you need it is imperative. For more guidance on how you and your loved ones can get covered, see the 300+ FAQs and find expert assistance on the Navigator Resource Guide.





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