Healthcare Enrollment Dates, Fees and a Delicate Dance for Coverage

There are so many costs associated with healthcare. To meet contractual requirements, each fee has a different name with specific stipulations. As insurance holders, members pay premiums for coverage to insurance companies and then pay providers directly until they meet their deduction before insurance starts to pay the bill, as well as, other out-of-pocket expenses that are almost never covered like over the counter prescriptions. It is costly for patients to satisfy the minimum fee requirements before insurance kicks in. Especially, as providers refuse to negotiate with patients the same way they do with insurance companies. 

Some plans will specifically cap the out-of-pocket expenses for a patient per visit so their deductibles are met based on a percentage of each service. An example is $25 for your primary care provider, $50 for specialists and $25 per prescription. This type of plan makes it so the insurance and the providers are always negotiating a patient’s care. Providers are limited by their agreement made with the insurance company over the standard cost of care for all visits.

Other plans, do not set limits on out-of-pocket expenses for each service, at the time of service. Instead they rely on the patient to pay each provider in full until their entire deductible is met. This is where providers are released from only charging based on the standard cost of care. While some providers will negotiate care with ease, others are not and know that a patient, before meeting their deductible are the deep pockets available for service. 

Unfortunately, with deductibles averaging over 7k for a single person – 12k for a family, paying these fees can be prohibitively expensive for patients. 1 in 4 Americans will refuse needed care because of the cost, even when they have insurance. Americans with health insurance coverage dropped for the first time in years this year.

Clients have called my office and told me that some providers are requiring credit cards on file and payment for services before they even see a doctor. Once that bill has been prepaid, it is almost impossible to negotiate the fees based on any standard cost of care because the provider has avoided it. The credit card company doesn’t care, your bill is still due and now a patient will also be responsible for interest fees until they can pay the bill in full. If patients are reimbursed by an insurance plan, the insurer knows what is the standard and will send that amount to the patient first, leaving the patient to either appeal or accept. 

Such tactics make it very difficult for patients to assert their rights as informed purchasers. As Associated Health Plans, Cost-Sharing Organizations and Self-Insured Companies expand cost coverage options, providers and insurance companies are crafting a delicate dance to sidestep one another and leave the patient out on their own to negotiate care and then foot the majority of the bill. What is unfortunate about this dynamic is when a client comes to me who has paid a company thousands of dollars over many years, never really needed healthcare and then when they do, are denied coverage or are left with prohibitive balances. 

There are some protections in place to avoid plans and organizations that don’t negotiate with providers directly. It requires signing up for a plan within the Affordable Healthcare Act Market  which only has open enrollment from Nov. 1 2019- Dec. 15, 2019 for coverage to start on Jan. 1 2020 so long as the first premium has been paid. The market is closed after Dec. 15th unless someone meets special requirements to apply, like losing a job. Medicare’s open enrollment period is October 15 – December 7. During these open enrollment periods the insured can change plans for care and prescriptions. For families and individuals who qualify for Medicare or Children’s Health Insurance Program because of demonstrated financial needs, they can enroll at any time, if enrolled before the 15th of the month their coverage from their plan and Medicare will kick on the first of the month that they enrolled. If their application is after the 15th then coverage in a plan will not start until the month after enrollment and any costs for care will be covered via Medicare directly or be reimbursed. 

MedWise takes pride in our ability to negotiate medical bills, it helps when our clients have insurance and follow their plan protocols to stay in network and seek out pre-authorization when possible. We hope that everyone has a happy holiday and that you take time during this break to sit, talk with your family about healthcare for the new year and then immediately take time to sign-up.  

Sign-up for Healthcare Here.

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