Your own healthcare costs don’t have to be a secret

0

A California law signed by Governor Gavin Newsom last month can help you sort through a jumble of medical bills to find out what your health plan covers and when coverage starts.

This article was published in Kaiser Health News on Monday, November 15, 2021.

By Bernard J. Wolfson

If you’ve ever had a serious illness or cared for someone who has it, you know how quickly medical bills can pile up: from laboratories, radiology clinics, pharmacies, doctors, different departments within the same hospital – some of them in your insurance network, others don’t.

Determining what bills to pay can be very confusing, no matter how smart you are. If you’re sick or have technological, cultural, or language barriers – not to mention financial difficulties – navigating this maze can be especially intimidating.

A California law signed by Governor Gavin Newsom last month can help you sort through a jumble of medical bills to find out what your health plan covers and when coverage starts.

The law, SB 368, requires most government-regulated private health insurers to send updates to patients for each month they received care showing how much they paid for their annual deductible – the amount that a person must pay before insurance begins to cover most of their care – and how close they are to reaching the deductible limit, the amount above which the insurer pays for 100% of care.

The law, which comes into effect in July, is designed to help people with costly chronic illnesses who need to keep a better eye on their debts, and healthy people who rarely seek help but suddenly face unexpected medical circumstances.

“Getting to these highs isn’t that difficult, and it doesn’t take a cancer diagnosis to get there,” said Dylan Roby, professor of public health at the University of California-Irvine. “It could be a visit to the emergency room with a procedure. A broken leg could get you there pretty easily. “

The new law requires health insurers to send updates by post, unless the insured opts for electronic delivery. The information must also be stored in a format that the customer can access at any time.

SB 368 “is part of a larger need to be transparent about the risks posed by individuals,” says Roby.

Consumers often do not know what is available for free under the Affordable Care Act, including preventive services like screening tests and vaccinations. Most health insurance plans offered through Covered California, the state’s ACA marketplace, must also cover outpatient benefits, including imaging, specialist appointments, and physical therapy, before the deductible is paid.

One potential pitfall of the new law, Roby notes, is that insurers can only calculate numbers based on the claims they handle, and some doctors and other providers may take six months or more to file claims. This means that the information plans sent to the enrolled may be out of date.

Currently, state law does not place a specific obligation on insurers to inform policyholders of their current financial liabilities, but some plans already do – either in the “declaration of performance” they send after receiving treatment or in response to a customer request .

“This law requires an optional practice,” says Senator Monique Limón (D-Santa Barbara), who wrote the law. “And it’s good practice.”

With health insurance policies becoming increasingly popular with higher deductibles, the new law should be helpful to a growing number of people.

Between 2012 and 2020, the percentage of California employees with individual insurance who had an annual deductible of $ 1,000 or more quadrupled to 54%. And of the families who had a health insurance plan with a deductible, 70% had a deductible of $ 2,000 or more in the past year, compared to 31% eight years earlier.

For the cheapest California insured plans, the deductible this year is $ 6,300 for an individual and $ 12,600 for a family. And there is a separate deductible for prescription drugs (the new law requires health insurers to notify participants of any deductibles).

With increasing deductibles, the health insured see later in the year that the financial protection of their insurance begins. And in many cases, after they meet their deductibles, they will have to spend a thousand or more before reaching the spending limits for the year.

People with serious diagnoses such as cancer, HIV, multiple sclerosis, or cystic fibrosis often make such calculations.

Stacey Armato, a 41-year-old mother of three in Hermosa Beach, California, has a 6-year-old son with cystic fibrosis, a severe, progressive lung disease. Her son Massimo takes about a dozen drugs that cost thousands of dollars each month.

Armato and her family are luckier than many: they have good insurance that limits their total spending on Massimo’s care to around $ 6,000 a year. But that’s still enough to sometimes make them rethink their spending plans. “I will always give priority to caring for my son,” says Armato.

She likes the new law. “I think transparency about how much a patient is spending and what their financial obligations are is very important,” she says.

Some families coping with cystic fibrosis and other expensive diseases face much bigger tradeoffs – for example, between getting treatment and paying their rent. In these cases it can be imperative to know when the financial bleeding will stop, which eases the burden on the family budget.

The new law can also make sense if, like many people, you have postponed an elective operation – for example a hip prosthesis or cataract removal – and now want to postpone it because of the pandemic. The best time, financially, is when you are close to reaching your deductible and spending limit – or when you have already reached them. Knowing where you stand will allow you to schedule the procedure for a time when your financial burden is minimal.

The law could also help people avoid money they don’t really owe. “Sometimes people think when people see some kind of bill they have to pay it,” says Jen Flory, a political attorney at the Western Center on Law & Poverty who supported the legislation. “Unless they understand, ‘Oh, I have reached my deductible or my maximum deductible,’ people will panic and do whatever they have to do to pay the bill. And it can be difficult to get the money back from the providers if they pay unnecessarily. “

Although your insurer is not obliged to disclose your cash payment status until the law comes into force in July, you can still call the customer hotline and ask for it – or to clarify an invoice. If you don’t get the answer you want, ask your health plan to let you know who’s taking care of this and give that authority a call. Usually this is the Department of Managed Health Care at 888-466-2219 or HealthHelp.ca.gov or the California Department of Insurance at 800-927-4357.

If you need help sorting medical bills, you can hire a professional patient advocate who will usually charge you a percentage of the amount they save you. To find patient advocates in your area, log on to www.advoconnection.com. at

To find out if you are eligible for free help, try the Patient Advocate Foundation (www.patientadvocate.org or 800-532-5274), which helps people pay unaffordable health bills and also provides disease-specific, needs-based financial aid.

This story was produced by KHN, an editor of California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News is a national health policy news service that is part of the non-partisan Henry J. Kaiser Family Foundation.

Share.

Comments are closed.