MONEY Health Care

Who Covers the Costs of Preventive Surgery Like Angelina Jolie’s

Actress Angelina Jolie
Matt Sayles—Invision/AP

Faced with a genetic predisposition to cancer, Angelina Jolie opted for a preventive surgery to remove her ovaries and fallopian tubes. But can other women afford to do the same?

This week, actress and director Angelina Jolie took to the New York Times to announce a big decision: She had her ovaries and fallopian tubes surgically removed, a preventive measure meant to decrease her risk of ovarian and breast cancer. This surgery followed her preventive double mastectomy in 2013.

After losing her mother, grandmother, and aunt to cancer, Jolie underwent genetic testing and learned that she had a mutation in one of her BRCA genes, a tumor-suppressor gene. That means she too has an increased risk of developing breast cancer and ovarian cancer.

“I feel feminine, and grounded in the choices I am making for myself and my family,” Jolie wrote. “I know my children will never have to say, ‘Mom died of ovarian cancer.'”

The good news: If you share Jolie’s predisposition to cancer, the same treatment options are probably available to you. Most insurers will cover preventive surgery for women with a BRCA mutation, says Lisa Schlager, vice president for community affairs and public policy at Facing Our Risk of Cancer Empowered (FORCE), a nonprofit organization devoted to hereditary breast and ovarian cancer. (Generally, Medicare and Medicaid aren’t as generous, Schlager says.)

That’s been true for a long time—a 2001 study found that 97% of preventive surgeries for women with BRCA mutations were fully covered by insurance (except for deductibles and copays).

The surgery can be costly. According to HealthSparq, a health care costs transparency firm, the average national cost for the surgical removal of the ovaries and fallopian tubes is $12,381.

That’s the average insurer-negotiated price, based on actual claims data from 67 health plans. In other words, that’s the average price insurers have agreed to pay hospitals and health providers for the procedure. You can expect to pay a smaller portion of that cost, depending on your health plan’s deductible, co-pays and co-insurance.

Today, the average deductible for Americans with single, employer-subsidized health coverage is $1,217, which means most need to pay more than a grand out-of-pocket before insurance begins to cover the bulk of their costs, according to the Kaiser Family Foundation.

“It really depends on your insurance and your deductible,” Schlager says. “Some people have a very high deductible, and we’re referring them to services that provide financial assistance.”

Prices can also vary significantly by region. According to HealthSparq, the average cost of the procedure is $8,693 in Maryland, but $20,763 in San Francisco, a $12,070 price gap.

Market Average Cost
San Francisco – San Jose CA $20,763.06
San Diego CA $16,508.06
Miami – Fort Lauderdale FL $16,441.37
LA – Orange County CA $16,378.38
Houston TX $14,687.49
Austin – San Antonio TX $13,617.29
New York City – White Plains NY $13,591.84
Dallas – Fort Worth TX $13,404.92
New Orleans LA $12,049.43
Cinncinati – Dayton OH $11,987.74
Columbus OH $11,335.80
Albany NY $9,559.04
Washington DC – Arlington VA $8,747.73
Maryland $8,692.77
AVERAGE NATIONAL $12,380.55
PRICE GAP $12,070.29

But generally, insurers will cover the surgery. After all, “the surgeries are less expensive to the private insurers than if you were to get cancer,” Schlager says.

How do you know if you’re at risk? According to guidelines from the National Comprehensive Cancer Network, you should get screened for genetic abnormalities if any of your family members develop ovarian or fallopian tube cancer, breast cancer in both breasts, breast and ovarian cancer, breast cancer before age 50, male breast cancer, or other signs of hereditary breast-ovarian cancer syndrome. You should also get tested if more than one blood relative on the same side of your family has breast, ovarian, fallopian tube, prostate, pancreatic, or melanoma cancer. The U.S. Preventive Services Task Force, which helps implement the Affordable Care Act, made similar recommendations.

Schlager says the cost of genetic testing has “dropped substantially” in recent years, to between $1,500 and $4,000. Most insurers will cover genetic testing if you meet the national guidelines, but if your insurer refuses, some labs have financial assistance programs to limit your out-of-pocket cost to about $100, Schlager says.

Then you should meet with a genetic counselor. The Affordable Care Act mandates that health insurers cover genetic counseling with no cost-sharing if you have an increased risk of breast or ovarian cancer. That is to say, genetic counseling is a women’s preventive service that should be free to you, like birth control.

Jolie was quick to note that her choice isn’t the answer for everyone. “A positive BRCA test does not mean a leap to surgery,” Jolie wrote. “I have spoken to many doctors, surgeons and naturopaths. There are other options.”

A genetic counselor should help you understand the implications of preventive surgery and consider other less invasive—but less effective—measures, like increased cancer screenings. “It’s a very personal decision, and every family is different,” Schlager says. “Your first step is to talk to your doctor.”

MONEY Taxes

Why Obamacare Has Made Tax Filing an Even Bigger Headache This Year

piggy bank with band-aid on head
Getty Images

This is the first year that health reform crops up on your tax return. And a new study finds that many Americans who got help with health insurance premiums in 2014 now owe the IRS money.

This tax season, for the first time since the health law passed five years ago, consumers are facing its financial consequences. Whether they owe a penalty for not having health insurance or have to reconcile how much they got in premium tax credits against their incomes, many people have to contend with new tax forms and calculations. Experts say the worst may be yet to come.

When Christa Avampato, 39, bought a silver plan on the New York health insurance exchange last year, she was surprised and pleased to learn that she qualified for a $177 premium tax credit that is available to people with incomes between 100% and 400% of the federal poverty level. The tax credit, which was sent directly to her insurer every month, reduced the monthly payment for her $400 plan to $223.

A big check from a client at the end of last year pushed the self-employed consultant and content creator’s income higher than she had estimated. When she filed her income taxes earlier this month she got the bad news: She must repay $750 of the tax credit she’d received.

Avampato paid the bill out of her savings. Since her higher income meant she also owed more money on her federal and state income taxes, repaying the tax credit was “just rubbing salt in the wound,” Avampato says. But she’s not complaining. The tax credit made her coverage much more affordable. Going forward, she says she’ll just keep in mind that repayment is a possibility.

It’s hard to hit the income estimate on the nose, and changes in family status can also throw off the annual household income estimate on which the premium tax credit amount is based.

Like Avampato, half of people who received premium tax credits would have to repay some portion of the amount, according to estimates by The Kaiser Family Foundation. Forty-five percent would get a refund, according to the KFF analysis. The average repayment and the average refund would both be a little under $800. (KHN is an editorially independent program of the foundation.)

Tax preparer H&R Block has also looked at the issue. It reported that 52% of people who enrolled in coverage on the exchanges had to repay an average of $530 in premium tax credits, according to an analysis of the first six weeks of returns filed through tax preparer. About a third of marketplace enrollees got a tax credit refund of $365 on average, according to H&R Block.

The amount that people have to repay is capped based on their income. Still, someone earning 200% of the poverty level ($22,980) could owe several hundred dollars, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation. People whose income tops 400% of poverty ($45,960 for an individual) have to pay the entire premium tax credit back.

Experts say the message for taxpayers is clear: if your income or family status changes, go back to the marketplace now and as necessary throughout the year to adjust them so you can minimize repayment issues when your 2015 taxes are due.

Many people are learning about what the health law requires and how it affects them for the first time when they come in to file their taxes, says Tara Straw, a health policy analyst at the Center on Budget and Policy Priorities. For the past 10 years, Straw has managed a Volunteer Income Tax Assistance site in the District of Columbia as part of an Internal Revenue Service program that provides free tax preparation services for lower income people.

Some of the recently initiated owe a penalty for not having health insurance. For 2014, the penalty is the greater of $95 or 1% of income. The H&R Block analysis found that the average penalty people paid for not having insurance was $172. Consumers who learn they owe a penalty when they file their 2014 taxes can qualify for a special enrollment period to buy 2015 coverage if they haven’t already done so. That would protect them against a penalty on their next return.

People may be able to avoid the penalty by qualifying for an exemption. Tax preparers rely on software to help them complete people’s returns, including the forms used to reconcile premium tax credits and pay the penalty for not having insurance or apply for an exemption from the requirement. For the most part, the software is up to the task, Straw says, but it comes up short with some of the more complicated calculations.

Case in point: applying for the exemption from the health insurance requirement because coverage is unaffordable. Under the health law, if the minimum amount people would have to pay for employer coverage or a bronze level health plan is more than 8% of household income they don’t have to buy insurance. That situation is likely to be one of the most common reasons for claiming an exemption.

But to figure out whether someone qualifies, the software would have to incorporate details such as the cost of the second lowest cost silver plan (to calculate how much someone could receive in premium tax credits) and the lowest cost bronze plan in someone’s area. The software can’t do that, so tax preparers must complete the information by hand.

“That one in particular has been vexing,” says Straw.

The gnarliest filing challenges may yet come from people with complicated situations, such as those who had errors in the IRS form 1095A that reported how much they received in premium tax credits, experts say.

Take the example of a couple with a 20-year-old son living at home who bought a family policy on the exchange. If midway through the year the son gets a job and is no longer his parents’ dependent, the family’s premium tax credit calculation will be off. The family needs to work together to figure out the optimal way to divide the credit already received between the two tax returns. The goal is to maximize the benefit to the family and minimize any tax credit repayment they may face.

“A lot of tax software is just not designed for that kind of trial and error,” says Straw.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

MONEY Health Care

Good News. Obamacare Hasn’t Led to Less Health Coverage at Work

"Benefits Meeting" announcement on bulletin board
Getty Images—(c) KLH49

A new survey finds that so far employers don't seem to be cutting worker hours to get out of offering health insurance benefits.

There has been much hand wringing over the health law requirement that large employers this year offer insurance to workers who put in 30 or more hours a week or face penalties for not doing so. The new rules would cost employers a bundle, some fretted, as part-timers clamored for company coverage previously unavailable to them. Others worried that employers would cut workers’ hours to get under the cap.

A new study found that so far there’s little cause for concern: Average enrollment in company plans was essentially unchanged between 2014 and 2015 at 74% of all workers.

The survey of nearly 600 employers by benefits consultant Mercer found that in 2015 the average percentage of employees who were eligible for coverage increased one point to 88%, but it was offset by a drop in the enrollment of eligible workers of one point on average, to 83%.

Part of the explanation for the stable results stems from the fact that most employers were already in compliance, says Beth Umland, Mercer’s director of research for health and benefits.

In 2014, employees had to work 25 hours a week on average to be offered health insurance, according to Mercer. That figure has edged up since 2011, when it was 23 hours weekly, but is still well below the law’s 30-hour threshold.

Still, while the expansion in eligibility wasn’t a big change for many employers, “if you were impacted you were really impacted,” says Tracy Watts, Mercer’s national leader for health care reform.

Food and lodging companies were most affected by the new rules, with the average percentage of workers who were eligible for coverage increasing from 57% to 60%. Other industry sectors that felt the change included health care, where per diem nurses and other professionals take on short-term assignments, and higher education, which employs many part-time adjunct professors, says Watts.

But most employers aren’t changing their practices to discourage health plan enrollment, the survey found. Seventy-three percent said they had no plans to change, while 16% said they ensured that newly hired part-timers work fewer than 30 hours weekly, and 19% said they reduced the hours of employees who consistently or occasionally worked more than 30 hours a week.

Even though the health law aims to encourage employers to offer coverage by imposing fines on those who don’t do so, not all take advantage of the offer. Workers might not sign up because they have other options under the health law. Low-income workers may be eligible for Medicaid in states that have expanded coverage to adults with incomes up to 138% of the federal poverty level. Young people can stay on their parents’ plan until they turn 26 under the health law, and many people continue to get coverage through their spouses.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

MONEY Health Care

Your Boss May Be Able To Force You To Buy Health Insurance

The health reform law requires most companies to offer workers good health coverage. It also lets them enroll employees automatically.

Under the health law, large employers that don’t offer their full-time workers comprehensive, affordable health insurance face a fine. But some employers are taking it a step further and requiring workers to buy the company insurance, whether they want it or not. Many workers may have no choice but to comply.

Some workers are not pleased. One disgruntled reader wrote to Kaiser Health News: “My employer is requiring me to purchase health insurance and is automatically taking the premium out of my paycheck even though I don’t want to sign up for health insurance. Is this legal?”

The short answer is yes. Under the health law, employers with 100 or more full-time workers can enroll them in company coverage without their say so as long as the plan is affordable and adequate. That means the employee contribution is no more than 9.5% of the federal poverty guideline and the plan pays for at least 60% of covered medical expenses, on average.

“If you offer an employee minimum essential coverage that provides minimum value and is affordable, you need not provide an opt out,” says Seth Perretta, a partner at Groom Law Group, a Washington, D.C., firm specializing in employee benefits.

If a plan doesn’t meet those standards, however, employees must be given the opportunity to decline those company plans, under the health law. They can shop for coverage on the health insurance marketplaces and may qualify for premium tax credits if their income is between 100% and 400% of the federal poverty level.

Those premium subsidies aren’t available to workers whose employer offers good coverage that meets the law’s standards.

Experts say they don’t expect many employers to strong arm their workers into buying health insurance. Those that do may be confused about their responsibilities under the health law, mistakenly believing that in order to avoid penalties they have to enroll their workers in coverage.

“That is just dead wrong,” says Timothy Jost, a law professor at Washington and Lee University who’s an expert on the health law.

“Nothing in the Affordable Care Act directs employers to make their coverage mandatory for employees,” says a Treasury Department spokesperson. The law requires large employers “to either offer coverage or pay a fee if their full-time workers access tax credits to get coverage on their own in the marketplace.”

Employer penalties for not offering insurance that meets the health law’s standards can run up to $3,000 per employee.

For employers, forcing coverage on their workers could be counterproductive. “Do you really want to limit employees’ ability to select whether they get this coverage? What impact does that have from talent management perspective?” says Amy Bergner, managing director at human resources consultant PwC.

The practice of automatically enrolling employees in health insurance isn’t new. Many employers have been doing it for years. Some enroll new employees in the least expensive company plan, for example. But employees have generally had the option to opt out of the coverage if they wish.

Automatic enrollment makes it simple to satisfy the health law’s requirement that most people have health insurance, experts say.

The health law stipulates that employers with more than 200 full-time workers are required to enroll newly hired full-time employees in a plan unless the employee specifically opts out of the coverage. However, the provision won’t take effect until the Department of Labor issues regulations.

Employees who are unhappy about being required to buy into a company plan could complain to the Department of Labor, some experts say. It’s unclear whether such efforts would succeed.

Employment law experts point to a 2008 decision by the Department of Labor dealing with state laws that restrict employers from making deductions from workers’ paychecks without their consent. The department issued an advisory opinion saying that federal ERISA law pre-empted a Kentucky law that required an employer to get an employee’s written consent before withholding wages to contribute to a group health plan.

Although that decision doesn’t have the force of law, it suggests how the Labor Department views such issues, says Cheryl Hughes, a principal at Mercer’s Washington Resource Group.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

MONEY Millennials

Sorry, Oldsters, Tinder Isn’t the Only Thing That Costs More if You’re Over 30

Tinder on mobile phone
Cyberstock—Alamy

Getting older is hard enough by itself, but leaving your 20s can also mean a slew of price increases and new expenses.

It can be tough out there for the over-30 crowd. Not that I would know— I plan to be in my mid-20s forever. But judging by my older friends, the influx of “just turned 30 (frowny face)” Facebook statuses, and the popular media, the big three-oh is a sobering moment when one comes to terms with the end of youth, the inevitability of death, and the realization that one should maybe stop going out on Mondays.

And that’s not all. Crossing 30 also makes life more expensive. Here are five things that get pricier as millennials enter—or simply get closer to—their next decade:

Tinder
Yes, even hooking up gets more expensive after your 30th birthday. The popular dating app Tinder recently announced that older users will have to pay more for its premium service, Tinder Plus. The service, which removes ads and includes a variety of extra features, will cost Americans $9.99 a month—unless they’re over 29, in which case the price doubles, to $19.99.

Tinder says it isn’t gouging older users, it’s simply offering younger users a discount because they’re “more budget constrained,” but that’s a distinction without difference for everyone stuck paying higher fees.

Health insurance
Thanks to Obamacare, anyone under 26 can comfortably freeload remain on their parents’ insurance. But turn 27 and your health care situation could deteriorate before your eyes. No more mooching off Mom and Dad means you’ll be left with whatever health insurance your work offers, which can be more expensive per person than a family plan, especially if your parents work in an industry with generous benefits. (And that’s assuming you’re currently reimbursing your parents for insurance. Those who don’t will be in for an even harsher wakeup call.) Plus, if you’re unemployed, be prepared to buy individual insurance through health care exchanges, which can be more expensive still.

Gym membership
Having to work out is bad enough, but gym rats over 30 may also end up paying more for the privilege. Local YMCA branches typically offer “young adult” discounts. The age cap on this deal can be as low as 22 or as high as 29, but we’ve yet to see one that extends to people older than their 20s. An adult membership will generally run you about $100 more per year, and that’s not including the emotional cost of being called a no-longer-young “adult.”

Traveling in Europe
Going backpacking through Europe is one of the most stereotypical young-person things out there, so it sort of makes sense it would get more expensive as you get older. Accordingly, Eurail, one of the most popular and cost-effective ways to explore the European continent, is 35% cheaper for travelers under 26. Air travel also gets more expensive for grownup vacationers. STA Travel, which bills itself as a full-service travel retailer, offers special discounts on flights to customers under 26.

Theater tickets
Young fans of the stage are in luck: a huge number of theaters offer special 30-and-under discounts to this coveted demographic. This is especially true in New York City, but since theaters everywhere are struggling to attract a younger crowd, it’s likely you’ll see similar deals across the country. Some locations extend special offers to patrons as “old” as 35, but the farther you get into your 30s, the more you should expect to pay for your arts fix.

MONEY Obamacare

Everything You Need to Know About the Latest Challenge to Obamacare

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Next week the Supreme Court will hear arguments in a case that could have a huge impact on millions of consumers. Here's what it's all about.

The Affordable Care Act is once again before the Supreme Court.

On March 4, the justices will hear oral arguments in King v. Burwell, a case challenging the validity of tax subsidies helping millions of Americans buy health insurance if they don’t get it through an employer or the government. If the court rules against the Obama administration, those subsidies could be cut off for everyone in the three dozen states using healthcare.gov, the federal exchange website. A decision is expected by the end of June.

Here are five things you should know about the case and its potential consequences:

1. This case does NOT challenge the constitutionality of the health law.

The Supreme Court has already found the Affordable Care Act is constitutional. That was settled in 2012’s NFIB v. Sebelius.

At issue in this case is a line in the law stipulating that subsidies are available to those who sign up for coverage “through an exchange established by the state.” In issuing regulations to implement the subsidies in 2012, however, the IRS said that subsidies would also be available to those enrolling through the federal health insurance exchange. The agency noted Congress had never discussed limiting the subsidies to state-run exchanges and that making subsidies available to all “is consistent with the language, purpose and structure” of the law as a whole.

Last summer, the U.S. Court of Appeals for the Fourth Circuit in Richmond ruled that the regulations were a permissible interpretation of the law. While the three-judge panel agreed that the language in the law is “ambiguous,” they relied on so-called “Chevron deference,” a legal principle that takes its name from a 1984 Supreme Court ruling that held that courts must defer to a federal agency’s interpretation as long as that interpretation is not unreasonable.

Those challenging the law, however, insist that Congress intended to limit the subsidies to state exchanges. “As an inducement to state officials, the Act authorizes tax credits and subsidies for certain households that purchase health insurance through an Exchange, but restricts those entitlements to Exchanges created by states,” wrote Michael Cannon and Jonathan Adler, two of the fiercest critics of the IRS interpretation, in an article in the Health Matrix: Journal of Law-Medicine.

In any case, a ruling in favor of the challengers would affect only the subsidies available in the states using the federal exchange. Those in the 13 states operating their own exchanges would be unaffected. The rest of the health law, including its expansion of Medicaid and requirements for coverage of those with pre-existing conditions, would remain in effect.

2. If the court rules against the Obama administration, millions of people could be forced to give up their insurance.

A study by the Urban Institute found that if subsidies in the federal health exchange are disallowed, 9.3 million people could lose $28.8 billion of federal help paying for their insurance in just the first year. Since many of those people would not be able to afford insurance without government help, the number of uninsured could rise by 8.2 million people.

A separate study from the Urban Institute looked at those in danger of losing their coverage and found that most are low and moderate-income white, working adults who live in the South.

3. A ruling against the Obama administration could have other effects, too.

Experts say disallowing the subsidies in the federal exchange states could destabilize the entire individual insurance market, not just the exchanges in those states. Anticipating that only those most likely to need medical services will hold onto their plans, insurers would likely increase premiums for everyone in the state who buys their own insurance, no matter where they buy it from.

“If subsidies [in the federal exchange] are eliminated, premiums would increase by about 47%,” said Christine Eibner of the RAND Corporation, who co-authored a study projecting a 70% drop in enrollment.

Eliminating tax subsidies for individuals would also impact the law’s requirement that most larger employers provide health insurance. That’s because the penalty for not providing coverage only kicks in if a worker goes to the state health exchange and receives a subsidy. If there are no subsidies, there are also no employer penalties.

4. Consumers could lose subsidies almost immediately.

Supreme Court decisions generally take effect 25 days after they are issued. That could mean that subsidies would stop flowing as soon as July or August, assuming a decision in late June. Insurers can’t drop people for non-payment of their premiums for 90 days, although they have to continue to pay claims only for the first 30.

Although the law’s requirement that individuals have health insurance would remain in effect, no one is required to purchase coverage if the lowest-priced plan in their area costs more than 8% of their income. So without the subsidies, and with projected premium increases, many if not most people would become exempt.

5. Congress could make the entire issue go away by passing a one-page bill. But it won’t.

All Congress would have to do to restore the subsidies is pass a bill striking the line about subsidies being available through exchanges “established by the state.” But given how many Republicans oppose the law, leaders have already said they will not act to fix it. Republicans are still working to come up with a contingency plan should the ruling go against the subsidies. Even that will be difficult given their continuing ideological divides over health care.

States could solve the problem by setting up their own exchanges, but that is a lengthy and complicated process and in most cases requires the consent of state legislatures. And the Obama administration has no power to step in and fix things either, Health and Human Services Secretary Sylvia Burwell said in a letter to members of Congress.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

MONEY Ask the Expert

The Right Way to Kick Your Kid Off Your Health Insurance

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Q. I am covered by my employer’s health plan, but I’m not happy with it. My son is 21 and currently covered under my plan. While I realize that I am not eligible for Obamacare, I am curious if I can terminate my son’s policy so that he might be eligible.

A. Since the open enrollment period to sign up for coverage on the state marketplaces ended Feb. 15, in general people can’t enroll in a marketplace plan until next year’s open enrollment period rolls around.

If you drop your son from your employer plan, however, his loss of coverage could trigger a special enrollment period that allows him to sign up for a marketplace plan. Whether he’s entitled to a special enrollment period depends on whether his loss of coverage is considered voluntary, say officials at the Centers for Medicare & Medicaid Services.

In general, voluntarily dropping employer-sponsored coverage doesn’t trigger a special enrollment period for individuals or their family members. But if you drop your son’s coverage on his behalf without his consent, his loss of coverage wouldn’t be considered voluntary and your son could qualify, according to CMS.

Whether he’ll be eligible for premium tax credits to make marketplace coverage more affordable is another matter, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

If you claim him as your dependent, he generally won’t be eligible. If you don’t claim him as your dependent, he would have to qualify for subsidies based on his own income.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

MONEY Health Care

Why You’re Still Paying for Birth Control Even Though It’s “Free” Now

150211_FF_BirthControl
Laura Johansen—Getty Images

Most women with private health insurance can get contraception for free, but a lack of information means some are still paying out of pocket—even when they shouldn't be.

A record scratch sounded in my head one weeknight this January, when a pharmacist at my local drugstore told me my birth control pills would—for the first time—cost more than $50 a month.

Strange, I thought, since I could have sworn I heard contraception was one of the preventive health services that are free under the Affordable Care Act, and that the law was rapidly expanding access for most women, with at least 67% of insured women on the pill paying $0 (up from only 15% in 2012), according to a recent study by the Guttmacher Institute. Perplexing.

After all, I don’t work for an exempted religious organization or a company such as Hobby Lobby, which in a Supreme Court case last year won the right to deny contraceptive coverage because of conflicting beliefs. And the same pills—Ortho Tri-cyclen Lo—cost me nothing under my old health plan. Sure, I had switched insurance companies in the new year (to Aetna, the third largest in the country), but I’d opted for a high-premium Gold plan. A monthly copay on par with the cost of an iPod shuffle seemed hefty and unfair.

So I left the pharmacy empty handed and went home to call Aetna.

My happiness was brief when a customer service agent informed me that—while most brand-name pills had a copay—I could simply switch to a free generic version of the same compound. The problem? Turns out there is no generic version of Ortho Tri-cyclen Lo yet. So I was trapped, much like women whose insurance companies have denied them coverage for the NuvaRing, reasoning that they can take generic pills with the same hormones—even though the Department of Health and Human Services has been clear that the ring is a distinct form of contraception (and should therefore be free).

I hesitated to simply choose a different generic for a reason that should not surprise the many other women who have tried multiple birth control methods: Switching from pill to pill in the past caused me side effects, which thankfully subsided once I finally found one that worked for me.

“People respond differently to different pills and a change can cause side effects like irregular bleeding and headaches,” says Jill Rabin, an ob-gyn and professor at Hofstra North Shore-LIJ School of Medicine. “There’s no predicting how someone will do unless they try it.”

The pressure I felt to switch seemed especially unjust given this aspect of the law: While women can be charged a copay for brand name drugs when an equivalent generic is available, this Department of Labor FAQ explains, “if, however, a generic version is not available, or would not be medically appropriate for the patient” as determined by her doctor, “then a plan or issuer must provide coverage for the brand name drug … without cost-sharing.”

When I brought my dilemma (and the fact that I was a journalist planning to write about it) to Aetna’s director of communications, Susan Millerick, she took swift action. Within a week, I had my Ortho Tri-cyclen Lo, free of copay.

“It is always Aetna’s intent to abide by the laws that govern our health benefits coverage, and to fairly interpret and apply all laws and regulatory guidance on behalf of our customers and members,” Millerick wrote in an email.

Millerick’s explanation for what had happened suggests any woman would be wise to question any insurer denial for contraceptive; she said Aetna’s “service reps erred” in not telling me about the option to appeal the copay. I should have been told that I could just ask my doctor to call and verify that I really needed my pill and that a different generic would not suffice.

The good news for many women is that simply being informed of your options—and getting your doctor on your side—may be enough to go from paying a wallet-draining copay to nothing at all, says Rabin.

“Figuring out the best contraception that minimizes cost and maximizes efficacy is a conversation that should be between doctor and patient,” Rabin says. “Most doctors don’t want that decision taken out of their hands and would be happy to help make that call for their patients.”

For those women who encounter more resistance than I did—or find, as Kaiser Health News reported, that certain insurers are even trying to wriggle out of covering generics—there are other resources to turn to, like the National Women’s Law Center. Their website has clear instructions on how to fight back if you think your insurer is unfairly denying you free birth control, with templates for appeal letters and a free hotline (866-745-5487) for additional assistance.

Even with all the progress, thousands of women have been contacting the NWLC’s hotline in recent months after running into problems getting free contraceptives, says Mara Gandal-Powers, a lawyer at the NWLC.

Generally, the biggest obstacle to free birth control access right now is ignorance, she says. Many women—and their insurance representatives, doctors, and pharmacists—aren’t on the same page about whether their particular contraception should have a copay or not. Instead of doing a double take at the cost of their contraceptives, Gandal-Powers says, some women never question the charge.

That’s a compelling reason to double check your insurer, pharmacist, and even doctor’s assumptions.

“There is definitely a lot of education that still needs to happen,” says Gandal-Powers, “not just among women themselves but also among health care providers and pharmacists.”

Beyond a lack of education, a few more obstacles to universally free birth control remain. Besides the religious exemption, there’s also a subset of insurance plans that are “grandfathered” in such a way that they don’t have to cover contraception right away—though they will in coming years. Enrollment in grandfathered plans is dropping, with only 26% of covered workers enrolled in a grandfathered health plan in 2014, down from 56% in 2011, according to the Kaiser Family Foundation. Another exception is self-funded student plans.

The takeaway? If you’re paying more than $0 for birth control, it can’t hurt to do a little digging. If you are lucky (and persistent), you could end up pushing your insurer to better comply with the law—and save hundreds of dollars a year, to boot.

MONEY Health Care

Why Your Next Doctor’s Bill Could Be Surprisingly Painful

Figuring out if a medical provider is on your health insurance plan isn't always as straightforward as you'd think. And that can mean a much higher bill than you expect.

“Is this doctor in my insurance network?” is part of the litany of questions many people routinely ask when considering whether to see a particular doctor. Unfortunately, in some cases the answer may not be a simple yes or no.

That’s what Hannah Morgan learned when her husband needed surgery last fall to remove his appendix. When they met with the surgeon at the hospital emergency department near their Lexington, Ky., home, Morgan asked whether he was in the provider network for her husband’s individual policy, which he bought on the Kentucky health insurance exchange. The surgeon assured her that he was. When she got home, Morgan confirmed that he was in network using the online provider search tool for her husband’s plan.

But when she read the explanation of benefits form from the insurer, the surgeon’s services were billed at out-of-network rates, leaving the couple on the hook for $747.

The surgeon’s office later told her that he belonged to two different medical groups. One was in Morgan’s husband’s health plan network, the other wasn’t. Following multiple phone conversations with the surgeon’s office and the insurer, the in-network rates were applied and the Morgans’ share of the bill shrunk to $157.

“I did everything I was supposed to do,” says Morgan, 26. “You feel kind of hopeless. I thought I did it right, and there’s still another hoop to jump through.”

Consumers who use out-of-network providers can rack up huge bills, depending on the care required. Health maintenance organizations generally don’t cover any non-emergency services provided by physicians or hospitals outside the plan’s network of providers. Preferred provider organizations typically do cover out-of-network services, but pay a smaller percentage of the charges, 70% instead of 80%, for example. Out-of-network services may have higher deductibles and higher out-of-pocket maximums as well.

Although it’s not routine, physicians may belong to more than one medical group, say experts. Surgeons, for example, may join a couple of medical groups to expand the number of hospitals that they’re affiliated with.

Even then, sussing out in-network providers may not be straightforward. Just because a medical group is in someone’s provider network, consumers can’t be confident that all the physicians in the medical group are also in network.

“Physician groups can be in network even though individual physicians in that group may not be,” says Susan Pisano, a spokesperson for America’s Health Insurance Plans, a trade group.

That situation might occur if some of the physicians in a medical group agreed to accept the rates negotiated with an insurer, but others did not, says Dr. Jay Kaplan, an emergency physician who’s president-elect of the American College of Emergency Physicians. The physicians who didn’t accept the network rate would be out-of-network for a patient, even if other members of the medical group were in network.

Consumer advocates say the lack of transparency is unfair to consumers.

“It’s 2015. Federal law requires Americans to buy health insurance,” says Mark Rukavina, a principal at Community Health Advisors in Chestnut Hill, Mass. “There’s something fundamentally wrong when you can only figure out what questions to ask after the fact.”

In addition to confusion about doctors who are part of more than one practice, consumers may also run into billing troubles if their doctor operates practices in different locations and accepts different insurance plans at each, say billing experts.

A podiatrist may see patients at one office location two days a week, and at another office location the rest of the week. Each practice may accept different insurance plans, and a patient may be in network only at one location.

If the physician’s office submits the paperwork to the insurer with the tax identification number for the wrong office location, the patient may get hit with an out-of-network charge. In that case, the patient may have to contact the doctor’s staff and ask them to resubmit the charges through the other practice. Generally that should solve the problem, experts agree.

Adding to the confusion is the fact that even if a physician is in a consumer’s insurance network, the hospital or clinic she works at may not be or vice versa. When undergoing a procedure or treatment, the patient could get hit with out-of-network facility and other charges.

More consumers may face out-of-network problems as health plans shrink the size of their provider networks in an effort to keep costs down.

“Health plans work very hard to see that consumers have the information they need and resources to turn to when they have questions,” AHIP’s Pisano said, noting that the Healthcare Financial Management Association and AHIP’s foundation have online guides to help consumers. Still, she added, “There is clearly also a responsibility on the part of providers to be more transparent.”

Consumers such as Morgan shouldn’t have to bear the burden when that is unclear, says Rukavina.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

MONEY Health Care

The Obamacare Open Enrollment Deadline Has Been Extended

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You can get more time if you tried to buy health insurance on the federal marketplace—but some states are offering more generous grace periods.

Did you miss the February 15 deadline to buy health insurance for 2015? The Department of Health and Human Services announced that you may have one more week to get insured.

If you tried to buy health coverage on the federal marketplace but couldn’t because of long wait times or website glitches, you may qualify for this special enrollment period. If you bought health insurance through the federal marketplace last year, however, you will not be allowed to make any changes to your coverage during this one-week extension.

Try again by going back to HealthCare.gov from now through February 22. You’ll need to attest that you couldn’t enroll by the deadline because of a website or call center problem.

After the deadline, that’s it—you won’t be able to buy individual health insurance for 2015 unless you have you have a “qualifying life event,” like marrying, divorcing, having a baby, moving, or losing your health coverage.

If you live in one of the 13 states with their own exchanges or the District of Columbia, the rules are a little different. Most states have announced extensions of some sort. In some states, you get more time only if you tried to sign up before February 15; in others, everyone has more time. Check acasignups.net for a good round-up of state policies.

Washington state currently offers the longest deadline extension: Residents have until April 17 to enroll. “This is the first year that residents may incur a tax penalty for not having health insurance under the Affordable Care Act,” Richard Onizuka, chief executive officer of Washington’s exchange, told the Wall Street Journal. “This special enrollment window will allow these individuals—as well as those who experienced difficulty completing their applications—additional time to get enrolled for 2015 coverage.”

That’s right: If you were uninsured in 2014, you could owe a penalty on your taxes this year. This year, the penalty is either $95 per person in your family (capped at $285), or 1% of your income (capped at the price of the national average premium for a bronze plan), whichever is higher. Go uninsured in 2015 too, and you could owe even more next year.

For more on buying a policy for 2015, check out this full guide to Obamacare open enrollment.

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