MONEY Health Care

Why a Trip to the ER Could Cost You More Than You Expect

If a holiday weekend mishap sends you to the emergency room, watch your wallet. You shouldn't owe more if the hospital is outside your insurance network. But that could change if you're admitted.

When you need emergency care, chances are you aren’t going to pause to figure out whether the nearest hospital is in your health insurer’s network. Nor should you. That’s why the health law prohibits insurers from charging higher copayments or coinsurance for out-of-network emergency care. The law also prohibits plans from requiring pre-approval to visit an emergency department that is out of your provider network. (Plans that are grandfathered under the law don’t have to abide by these provisions.)

That’s all well and good. But there are some potential trouble spots that could leave you on the hook for substantially higher charges than you might expect.

Although the law protects patients from higher out-of-network cost sharing in the emergency room, if they’re admitted to the hospital, patients may owe out-of-network rates for the hospital stay, says Angela Gardner, an associate professor of emergency medicine at the University of Texas Southwestern in Dallas who is the former president of the American College of Emergency Physicians.

“Even if the admission is warranted, you are subject to those charges,” she says.

If you live in a state that permits balance billing by out-of-network providers, your financial exposure could be even greater. In a balance-billing situation, a hospital may try to collect from the patient the difference between what the hospital billed and what the health plan paid for care. Such practices aren’t generally allowed if a consumer visits an in-network provider.

Consumers shouldn’t expect that the hospital will inform them of potential out-of-network coverage issues, so they need to inquire, says Gardner.

“At least being informed and knowing what you’re getting into can set you up to handle it with your insurer,” she says.

And while you’re at it check into being transferred to an in-network facility if it’s feasible.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

TIME

Oregon Sues Oracle Over Failed Health Care Website

Attorney general candidate Ellen Rosenblum makes remarks during a debate with Dwight Holton at the City Club Friday, April 27, 2012, in Portland, Ore.
Attorney general candidate Ellen Rosenblum makes remarks during a debate with Dwight Holton at the City Club Friday, April 27, 2012, in Portland, Ore. Rick Bowmer—AP

(SALEM, Ore.) — The state of Oregon filed a lawsuit Friday against Oracle Corp. and several of its executives over the technology company’s role in creating the troubled website for the state’s online health insurance exchange.

The lawsuit, filed in Marion County Circuit Court in Salem, seeks more than $200 million in damages and alleges that Oracle officials made false statements and submitted false claims.

Oracle was the largest technology contractor working on Oregon’s health insurance enrollment website, known as Cover Oregon. The public website was never launched and became a political problem to Democratic Gov. John Kitzhaber, who is running for re-election.

“Today’s lawsuit clearly explains how egregiously Oracle has disserved Oregonians and our state agencies,” Attorney General Ellen Rosenblum, a Democrat, said in a statement. “Over the course of our investigation, it became abundantly clear that Oracle repeatedly lied and defrauded the state.”

Oracle filed its own lawsuit Aug. 8 alleging breach of contract and seeking payment of more than $23 million in disputed bills. The Redwood City, California, company blames Oregon for the website’s failure, saying the state had incompetent and indecisive staff.

Oracle officials could not immediately be reached for comment.

Instead of signing up for health insurance under the Affordable Care Act in one sitting, Oregonians had to use a hybrid paper-online process that was costly and slow, and the state had to hire more than 400 workers to help them. Altogether, about $250 million in federal funds has been spent on Oregon’s exchange, including technology development, salaries, advertising and rent.

Despite the exchange’s technology woes, about 454,500 Oregonians have enrolled in coverage through Cover Oregon using the hybrid process. An estimated 97,000 of those enrolled in private health plans, while about 357,500 enrolled in the Oregon Health Plan, the state’s version of Medicaid.

The state decided to stop building the Oracle website earlier this year and transitioned to the federally run enrollment website.

The FBI and the federal Government Accountability Office are also investigating Oregon’s exchange problems.

MONEY Health Care

How Some Insurers Still Avoid Covering Contraception

Locked up birth control pills
Nicholas Eveleigh—Getty Images

Under health reform, your birth control should be fully paid for by insurance. But even before the Supreme Court gave more employers an out, some insurers have been pushing back.

How much leeway do employers and insurers have in deciding whether they’ll cover contraceptives without charge and in determining which methods make the cut?

Not much, as it turns out, but that hasn’t stopped some from trying.

Kaiser Health News readers still write in regularly describing battles they’re waging to get the birth control coverage they’re entitled to.

In one of those messages recently, a woman said her insurer denied free coverage for the NuvaRing. This small plastic device, which is inserted into the vagina, works for three weeks at a time by releasing hormones similar to those used by birth control pills. She said her insurer told her she would be responsible for her contraceptive expenses unless she chooses an oral generic birth control pill. The NuvaRing costs between $15 and $80 a month, according to Planned Parenthood.

Under the health law, health plans have to cover the full range of FDA-approved birth control methods without any cost sharing by women, unless the plan falls into a limited number of categories that are excluded, either because it’s grandfathered under the law or it’s for is a religious employer or house of worship. Following the recent Supreme Court decision in the Hobby Lobby case, some private employers that have religious objections to providing birth control coverage as a free preventive benefit will also be excused from the requirement.

In addition, the federal government has given plans some flexibility by allowing them to use “reasonable medical management techniques” to keep their costs under control. So if there is both a generic and a brand-name version of a birth-control pill available, for example, a plan could decide to cover only the generic version without cost to the patient.

As for the NuvaRing, even though they may use the same hormones, the pill and the ring are different methods of birth control. As an official from the federal Department of Health and Human Services said in an email, “The pill, the ring and the patch are different types of hormonal methods … It is not permissible to cover only the pill, but not the ring or the patch.”

Guidance from the federal government clearly states that the full range of FDA-approved methods of birth control must be covered as a preventive benefit without cost sharing. That includes birth control pills, the ring or patch, intrauterine devices and sterilization, among others.

But despite federal guidance, “we’ve seen this happen, plenty,” says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. “Clearly insurance companies think things are ambiguous enough that they can get away with it.”

If you are denied coverage, your defense is to appeal the decision, and get your state insurance department involved.

“The state has the right and responsibility to enforce this law,” says Sonfield.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

More on the Affordable Care Act and contraception coverage:

 

 

 

 

 

TIME 2014 Election

This Democratic Senator Is Running on Obamacare in a Surprising New Ad

Hell freezes over

+ READ ARTICLE

Senator Mark Pryor (D-Ark.) is running in one of the tightest reelection races in the country, facing freshman Rep. Tom Cotton (R-Ark.), a U.S. Army veteran. So it may come as some surprise that in Pryor’s new ad released Wednesday, he chose to hone in on his support of President Barack Obama’s unpopular healthcare law.

In the personal new ad, Pryor’s father, David, a former senator himself, talks about his son’s battle with sarcoma, a rare form of cancer, in 1996. “When Mark was diagnosed with cancer, we thought we might lose him,” David Pryor says in a voiceover. “But you know what? Mark’s insurance company didn’t want to pay for the treatment that ultimately saved his life.”

By opening up about the struggle for his own life, Pryor aims to connect with his constituents. “No one should be fighting an insurance company when you’re fighting for your life,” he says in the ad. “That’s why I helped pass a law that prevents insurance companies from canceling your policy if you’re sick or deny coverage from preexisting conditions.”

Pryor’s ad does at least three things right. First, he hones in on the most popular aspect of the Affordable Care Act: coverage for those with preexisting conditions, which has support across the aisle. “We all agree that nobody should be denied coverage due to a pre-existing condition,” David Ray, a Cotton campaign spokesman, told TIME in an emailed statement.

Second, Pryor’s ad doesn’t use the term “Obamacare,” the Affordable Care Act’s nickname first coined by its critics. A Kaiser Health Tracking poll released August 1 found that a little over half of the public—53%—have an unfavorable view of Obamacare. But when referred to by a different name, the law’s negative ratings can decrease, polls show. One Kentucky poll in May found that while 57% of registered voters disliked “Obamacare,” only 22 percent had unfavorable views of Kynect, the state exchange created as a result of the Affordable Care Act’s passage in 2010.

Third, the ad includes his father, a former Congressman, Senator and Governor who is still a popular advocate despite being out of office for the better part of two decades.

And as Pryor runs on Obamacare, Senate Republican candidates and their supporters across the country have backed off on their attacks against the law. In April, anti-Obamacare advertising accounted for 54 percent of the issue ads in North Carolina, and almost all ads in Louisiana were focused on the health care law, according to Kantar Media’s Campaign Media Analysis Group, as reported by Bloomberg. But by July, that number dropped to 27% in North Carolina and 41% in Louisiana.

This shift could be for a variety of reasons, including a renewed focus on the economy and jobs in this election cycle. But Republicans might also be reacting to a law that beat expectations, with higher enrollment figures and fewer than expected cancelled plans (1.9 million versus the purported 4.8 million, according to Health Affairs.) In Arkansas, the law reduced the percentage of uninsured from 22.5% to 12.4% over last year, according to Gallup. That 10.1% decline is the largest of any state in the nation.

Of course, Republicans stated goal on Obamacare remains “repeal and replace,” and ads could reemerge this fall even if premiums don’t increase. David Ray, a campaign spokesman for Pyror’s opponent, Cotton, told TIME in an emailed statement that the aforementioned pre-existing condition provision makes sense, but overall the law should be overturned as it raises health care costs and taxes and lowers wages.

“We thank God that Senator Pryor survived cancer, and we admire his courage in that fight,” wrote Ray. “However, we didn’t need Obamacare to change insurance regulations. We all agree that nobody should be denied coverage due to a pre-existing condition. Obamacare raises taxes on the middle class, has caused millions of Americans to lose insurance plans they were promised they could keep, has doubled or even tripled premiums on families who can’t afford it, has caused lost wages and hours at work, and is preventing many small businesses from growing and hiring more people. Further, Senator Pryor has supported a taxpayer-funded bailout of big insurance companies that lose money as a result of Obamacare. We need to start over with reform that makes healthcare more affordable and keeps healthcare decisions between patients and doctors.”

MONEY Ask the Expert

When Parents Can Say No to Picking Up the Tab for Insurance

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Q. My ex-husband has been responsible for providing health insurance for our kids until the age of majority. My sons are now 21 and almost 18. My ex has family coverage for himself and his new wife, but he wants me to put the kids on my insurance now that they have reached the age of majority. Covering the kids doesn’t cost him anything extra, but for me to switch from a single plan to a family plan is an extra $175 a month and I can’t afford it. Since the age of majority for health insurance is now 26, is it possible he still is required to keep them on his insurance?

A. No, he’s not obligated to keep them on his health plan. Under the health law, insurers must offer to cover young adults up to age 26, but parents aren’t obligated to provide it, says Timothy Jost, a law professor at Washington and Lee University and an expert on the health law.

Further, the requirement to offer coverage isn’t related to the age of majority, which is defined by individual states and is generally between 18 and 21, says Randy Kessler, an Atlanta divorce lawyer and past chair of the American Bar Association’s family law section.

The health insurance coverage arrangement that you describe is pretty typical, says Kessler. You could go back to court and try to get your child-support payments increased to cover the cost of providing health insurance for the kids, but “it would be unusual for the courts to be helpful,” says Kessler. Absent some significant change in your or your ex-husband’s finances, or unforeseen and costly medical expenses for your children, in general “you can’t have another bite at the apple.”

With no legal requirement to compel either of you to cover your kids, it’s something the two of you will just have to work out, says Kessler. In addition to covering your children on your own or your ex’s plan, it’s also worth exploring whether they might qualify for subsidized coverage on the state marketplaces or for Medicaid, if your state has expanded coverage to childless adults. If they’re in college, student health coverage is worth investigating as well.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Health Care

WATCH: Walmart Wants to Be Your Doctor

Walmart is testing in-store health clinics in select parts of Texas and South Carolina.

MONEY Health Care

How to Find Health Coverage To Fill a Gap

Short-term insurance plans have major shortcomings, but having one will at least protect your from catastrophic costs.

Consumers who missed open enrollment on the state health insurance marketplaces this spring or who are waiting for employer coverage to start don’t have to “go bare.” Short-term policies that last from 30 days up to a year can help bridge the gap and offer some protection from unexpected medical expenses. But these plans provide far from comprehensive coverage, and buyers need to understand their limitations.

In contrast to regular health plans, applicants for short-term coverage may be rejected because they have pre-existing medical conditions.

Even if they’re accepted by the plan, the drugs and medical care necessary to manage their diabetes, for example, generally wouldn’t be covered, says Carrie McLean, director of customer care at online health insurance vendor ehealth.com.

Nor do short-term plans typically cover preventive care or pregnancy and maternity services.

“It’s not going to function like a regular health plan,” says McLean.

Lifetime coverage maximums are typical as are high deductibles. Between April and June, the average deductible for short-term individual plans sold by ehealth.com was $3,391, while families faced an average deductible of $8,252. Premiums averaged $107 for individuals and $249 for families.

Plans with similar limitations and restrictions used to be commonplace on the individual market. But the health law changed that. Today, regular insurance plans sold on the individual and small group markets must all cover a comprehensive set of 10 “essential health benefits,” and they can no longer turn people away because they have pre-existing medical conditions.

The 2014 enrollment for these plans ended in March, but some people who have specific changes in their life, such as losing job-based coverage or having a baby, can still get a special enrollment period to sign up for regular insurance plans.

Because short-term plans don’t meet the standards of the health law for “minimum essential coverage,” they also expose consumers to the health law penalty for not having health insurance of $95 or 1% of income, whichever is greater.

So why would someone buy a short-term plan, anyway? Basically, it provides some protection against catastrophic hit-by-a-bus expenses. Some consumers are looking for just that.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Read more about the impact of health reform:

MONEY Health Care

Here’s One Thing That’s Cheaper in the City, and It Will Help You Live Longer

New York City Cityscape
Hint: It's not rent. Charles Taylor Crothers—GalleryStock

In some states, rural residents are paying far more for health insurance. Here's why—and why that might change next year.

By many measures, city living is a racket: skyrocketing rents, expensive food, and pricy entertainment options can make for a high cost of living. But a new study from the Robert Wood Johnson Foundation finds that city residents have the slight edge on one metric: this year they had access to cheaper individual health insurance plans on the state and federal exchanges that were created under Obamacare.

Nationally, rural residents pay only slightly more: A 50-year-old nonsmoker from a rural county is spending $387 a month on average for a mid-tier silver plan in 2014, while a city denizens pay $369 for the same kind of plan, the study found. But in some states the gap is much wider.

In Nevada, for example, residents of rural counties must spend an average of $554 a month for a silver plan—57% more than their urban peers. In eight other states, country consumers are charged at least $50 a month more for the same healthcare coverage.

A chief reason for higher premiums, researchers believe, is a lack of competition. Rural areas are home to fewer doctors, which makes it hard for insurers to score discounts for their policyholders. And rural residents have fewer health insurance options. This year, on average, urban health-care shoppers had their pick of five insurers on the exchanges, the study found; those who live in rural areas had only 3.8 options. Also, urban shoppers were able to choose from one of 17 plans on average, while rural consumers saw an average of 14.2 plan options.

Another problem is that insurance is sold on a state-by-state basis, says Janet Weiner, associate director for health policy at the Leonard Davis Institute of Health Economics. Take Nevada. In a few rural counties bordering Utah and California, there aren’t that many doctors and hospitals, and many of the closest ones are out-of-state. “The insurers do not sell multi-state plans, and so even if there are more providers close by, but across state lines, they cannot expand their provider networks,” Weiner says. “This limits the ability of insurers to drive discounts and keep costs down.”

The potential good news? Rural residents could see some relief in 2015 as more insurers join the exchanges (open enrollment starts on Nov. 15). While some states, including Florida and California, have already announced premium hikes for next year, new insurers could inject some much-needed competition into the marketplaces. For instance, both Cigna and Aetna have announced plans to expand into Georgia, a state where rural customers currently pay 24% more than urban customers do for the same kind of plan. UnitedHealthcare, the nations’ largest insurer, has announced that it will sell policies on far more state exchanges next year. “If insurers see a business opportunity, rural areas may be in luck,” Weiner says.

Read more about the impact of health reform:

 

MONEY Health Care

The Hidden Health Care Subsidy for the Rich

Waiter holding silver platter
AndyL—Getty Images

If a recent appeals court decision holds up, many middle-class families will lose federal subsidies to buy insurance. But high-income families can still get help.

A recent decision by a federal appeals court has put an essential feature of the Affordable Care Act, better known as Obamacare, in danger. That ruling may not stand up in the next round of appeal. But if the court’s decision survives, it will create a troubling—and, I would argue, outright perverse—inequality.

The quick backstory: Opponents of the new health care law argued in court that a strict reading of the law doesn’t allow the federal government to subsidize individual insurance premiums in states that have not set up their own “exchanges,” online marketplaces where people can go to buy coverage. The D.C. circuit court agreed, while another court the same day reached the opposite conclusion, setting up a likely showdown in the Supreme Court next year. If the ruling stands, millions of people in up to 36 states could lose federal tax credits that helped make insurance affordable.

What’s so perverse about this is that while many low-income and middle-income people would no longer get help from the federal government to buy insurance, loads of affluent people still will.

Here’s why: Even before Obamacare, the federal government played a big, but hidden, role in funding the private health insurance of most working-age people. When you get insurance at work, the money your employer pays for your premiums isn’t included in your taxable compensation. That’s a valuable tax benefit to you, but that lost revenue costs the government just as much as if was cutting a check.

This system has done a lot to encourage companies to offer health insurance, which is a good thing. But it also had a surprisingly backwards effect. Affluent people are more likely to have coverage (and costlier coverage, too). And because they face higher tax rates, they benefit more from tax breaks. As a result, you get more from this hidden subsidy the more you earn. The Tax Policy Center recently estimated that the average benefit of the health-insurance tax break is about $800 for a household in the middle 20% of earners. For people in the top 20%, it’s $3,400.

Prior to the Affordable Care Act, tax subsidies for health care you bought for yourself were much stingier. One of the points of the law was to address this gap. Families earning less than 400% of the poverty line—as high as about $95,000 for a family of four—currently get a tax credit when they buy coverage on a state exchange or the federal Healthcare.gov. Now that particular subsidy is under threat in some states. But the tax break for employer insurance will still be around for those fortunate enough to have an employer who pays up for premiums.

Of course, if this happens—and I should stress if—it wouldn’t exactly be new. This is how health insurance worked everywhere in the country before the ACA. But people on both sides of the political spectrum knew that was a crazy system. And now, the difference would be all the more glaring, since some Americans buying their own insurance would still get help, and others wouldn’t—all based on the technicality of whether their state set up a website.

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