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When people sign up for a new health insurance plan, be that an employer-sponsored plan or one purchased on the Affordable Care Act (ACA) exchange, they can often be confused about when coverage starts, what is covered and whether they have to share in the medical bills.
The Kaiser Family Foundation recently compiled a list of seven takeaways from stories about people who ended up paying large out-of-pocket expenses for medical care. Health plan enrollees should read the following to learn how they can better use their plan and avoid financial blowback.
1. Most insurance coverage doesn’t start immediately
Many new plans come with waiting periods, so it’s important to maintain continuous coverage until a new plan kicks in.
One exception: An employee can opt into a COBRA policy or purchase a plan on the ACA marketplace (healthcare.gov or a state-run plan in certain states) within 60 days of losing their job-based coverage. With COBRA, once you pay, the coverage applies retroactively, even for care received while you were temporarily uninsured.
They will also qualify for a special enrollment period on the ACA marketplace to get coverage for the rest of the year. Coverage can start the first day of the month after someone loses their employer-sponsored coverage.
2. Check coverage before checking in
Some plans come with unexpected restrictions, potentially affecting coverage for care ranging from contraception to immunizations and cancer screenings.
Enrollees should call their insurer — or, for job-based insurance, their human resources department or retiree benefits office — and ask whether there are exclusions for the care they need, including per-day or per-policy-period caps, and what they can expect to pay out-of-pocket.
3. ‘Covered’ does not mean insurance will pay
Carefully read the fine print on network gap exceptions, prior authorizations and other insurance approvals. The terms may be limited to certain doctors, services and dates.
Also, while the service may be covered, sometimes it won’t be until the deductible or out-of-pocket maximum is met.
4. Get estimates for nonemergency procedures
Before scheduling a nonemergency procedure, an enrollee may be able to shop around among different providers that offer the procedure. Request estimates in writing and if an enrollee objects to the price, they should negotiate before undergoing care.
5. Location matters
Prices can vary depending on where a patient receives care and where tests are performed. If a patient needs blood work, they should ask their doctor to send the requisition to an in-network lab.
A doctor’s office connected to a health system, for instance, may send samples to a hospital lab, which can mean higher charges if it’s not in-network.
6. When admitted, contact the billing office early
When an enrollee or a loved one has been hospitalized, it can help to speak to a billing representative if possible. Questions to ask:
- Has the patient been fully admitted or are they being kept under observation status?
- Has the care been determined to be “medically necessary?”
- If a transfer to another facility is recommended, is the ambulance service in-network or is it possible to choose one that is?
7. Ask for a discount
Medical charges are almost always higher than what insurers would pay, and providers expect them to negotiate lower rates. Health plan enrollees can also negotiate.
Uninsured or underinsured patients may be eligible for self-pay or charity care discounts.
