This information can help you understand details about your premiums, processes and claims so you know what happens as you use your health plan.
Understanding premiums and coverage periods (for plans you buy on your own)
Getting a refund when you overpay
For individual and family plans, if you overpay your premium, we’ll credit your account or we can mail you a check for the amount. For help with an overpayment, you can log in to your member site to send a secure message or call customer service at the number on the back of your member ID card.
For ease and convenience, you can pay your premium online. Learn about paying your premium online.
Grace periods for coverage
Your premium needs to be paid before your coverage begins or continues. Your coverage may have a grace period. This is when coverage continues even though your premium for the upcoming period has not been paid.
The length of the grace period varies based on how you bought your plan.
If you bought your health plan through MNsure and are getting advance payments of the premium tax credit:
You’ll have a grace period for three consecutive months if you’ve previously paid at least one full month’s premium during the benefit year. During the grace period, we will pay all appropriate claims for care you received during the first month. Claims for care during the second and third months may not be paid immediately (they will be "pended"). You may also have to pay for prescriptions during the second and third months of the grace period.
If we don’t receive your premium payment by the end of the three month grace period, your coverage will be canceled back to the last day of the first month of the grace period. You are then responsible for paying for all your care from the second and third months of the grace period.
If you bought a health plan directly from us, or you bought it through MNsure and are NOT getting advance payments of the premium tax credit:
We allow a 31-day grace period for payment, rather than three months.
In either case, if your coverage is canceled for nonpayment, you may not be able to get new individual and family health insurance coverage again until the next annual enrollment period unless you experience a qualifying event.
Things to know before you get care
Your costs are much higher when you get care outside your network
A network is a group of doctors, clinics, hospitals and other health care providers that you can see for a lower cost. If you choose to see providers that are not in your plan’s network, you will likely have to pay more for — or even all of — the cost of that care, so it’s important to stay in your network.
Here are some ways the cost for seeing an out-of-network provider are higher:
- You’ll be responsible for any deductibles or coinsurance, which are generally higher than they are for in-network care.
- You’ll pay the difference between what we would reimburse the provider and what they bill (this is sometimes called "balance billing"). The difference you pay does not help you meet your out-of-pocket maximum.
- Some plans, including individual and family plans available in Minnesota, do not have an out-of-pocket maximum for out-of-network care. That means your plan will not start paying 100 percent of covered services for out-of-network care even if your expenses are very high. If you visit a doctor or facility that’s not in your network for an expensive procedure, you could owe them many thousands of dollars that are not covered by your insurance.
Please be sure to check that doctors and facilities are in your network before you visit them.
Sometimes there are exceptions, such as emergency situations. You should check your health plan documents to make sure you understand the details about your in- and out-of-network coverage.
Medical necessity and prior authorization
We want to ensure that you’re getting reasonable, necessary and appropriate care – care that’s considered “medically necessary.” To do that, we need your doctor to give us a prior authorization request.
To confirm that care is medically necessary, we review the authorization request using our medical policy, which includes established clinical guidelines from the World Health Organization, which are regularly reviewed by doctors and nurses.
Some treatments may need prior authorization and may be reviewed for medical necessity. Not all services need this. Your health plan contract lists the treatments and procedures that require prior authorization.
If possible, get prior authorization before you receive treatment. In most cases, the doctor who schedules the service or procedure will get the prior authorization. If you don't have prior authorization before you receive treatment, the claim for the treatment can be denied if it is later found to be not medically necessary.
Time frames for decisions about authorizations: In general, decisions about coverage take approximately 10 business days. If your doctor believes your medical condition requires as fast decision, the doctor can request a fast review.
Learn more about prior authorization and medical policy.
Exceptions for drug coverage
Health plans that include prescription drug coverage work with a “formulary,” or list of covered drugs. Not all drugs are covered.
Search a drug list or find a pharmacy. (You'll need to know the name of your formulary.)
Sometimes, if your doctor feels that there isn’t a covered drug that meets your needs, he or she can request an exception so the drug can be covered by your plan.
How to request an exception: To get an exception, you or your doctor can complete an online drug coverage exception request form.
Time frames for decisions about exceptions: In general, decisions about coverage take approximately 10 business days. If waiting for a standard decision could seriously harm you, you can ask for and we will give you a fast decision. To request a fast decision, select the "I need an expedited decision" box on the online form.
Learn more about prescription drugs and understanding your prescription drug benefits.
About claims and explanations of benefits
Submitting claims
If you visit an in-network doctor, hospital or other health care provider, you don’t need to submit a claim to us. Your provider will submit the claim for you.
If you visit an out-of-network doctor, hospital or other health care provider, you will need to submit one of these claim forms to us within the time noted in your contract.
Different plans may use different claim forms. Each form shows information you need to provide with the form, along with contact information for you to submit the form in the way you choose: mail, fax or email.
If you have questions about claims, please call customer service at the number on the back of your member ID card or log in to your member site and send a secure message.
About claims being denied after they’ve been paid: It's rare, but it's possible for a claim to be denied after it's been paid ("retroactively"). If this happens, you're responsible for paying your doctor for the cost of care you received.
How can claims be denied and how can your avoid it?
- It can happen if you haven't paid your premium for the time when you received care, so be sure to pay your premium on time.
- It can happen if we've made a mistake and paid too much to a provider – if we've paid for a part of a cost that was actually your responsibility, you'll need to pay your part to the provider.
Learn about tracking claims online and claims summaries.
Explanations of benefits
After you use your health plan benefits and we receive a claim for payment from your provider, we will send you an Explanation of Benefits (EOB). An EOB is not a bill, but it helps you keep track of some important information, including:
- The health care services you received
- How much your health plan paid your provider
- How much you owe your provider for your care
Learn more about EOBs and how to read them.
Coordination of benefits
If you, your spouse or your covered dependents are covered by more than one health plan, we work with your other plan to coordinate how your expenses are paid by each plan.
Need help?
Learn about forms, FAQs, health plans, your member site and more.