ADJUSTING TO LIFE IN A PANDEMIC
Paying for Healthcare in the Age of A Corona virus
ILLUSTRATION: BEN SHMULEVITCH
Even before the coronavirus outbreak hit earlier this year, Americans’ finances were fragile. Four in 10 people in the U.S. said that in the previous two years they’d had an out-of-pocket medical bill of at least $400, and half said they were extremely or very concerned about being able to afford it, according to a nationally representative Consumer Reports survey of 1,079 adults fielded in early March.
As the coronavirus continues its destructive path, the financial situation has become even more dire: By early April, more than 16 million Americans had already lost their jobs—and often the health insurance that comes with their employment.
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These realities put the shortcomings of our healthcare system—how care is paid for, who has access—into even starker relief. A Kaiser Family Foundation (KFF) poll published in mid-March—before much of the country shut down to stem the spread of the virus—found that one-third of people worried they couldn’t afford coronavirus testing or treatments if they were sickened by the virus.
MORE ON CORONAVIRUS
The uninsured are the most financially vulnerable. But cost can also be a struggle for the estimated 81 million Americans who have high-deductible health plans (HDHPs); they must first pay at least $1,400 out of pocket for an individual or $2,800 for a family before coverage begins.
Another problem, even for people with health coverage, is surprise medical bills, which people can face when they get care from an out-of-network provider, as can happen in emergencies.
To blunt some of the financial fallout, President Donald Trump in March signed the Families First Coronavirus Response Act. The law mandates that all insurance plans—Medicare, Medicaid, military, Affordable Care Act (ACA), and employer—cover the cost of a coronavirus test, roughly $50, and any related doctor’s appointment copays or fees. But it might not address all other healthcare or hospital costs related to the coronavirus or the surprise medical bills a consumer may face.
Those additional costs can be substantial, even just to get a diagnosis. That’s because in addition to the coronavirus test, doctors sometimes need to administer other blood tests and sometimes X-rays to rule out the flu or pneumonia.
For example, a person in Seattle with severe symptoms of the coronavirus—high fever, cough, and significant trouble breathing—who goes to a doctor’s office can expect to pay about $1,000 for the appointment and testing, according to an analysis from Castlight Health (PDF), a group that works with employers to lower healthcare costs. In some places, such as New York City and Miami, prices could be even higher.
“Treatments for COVID-19 could be especially expensive if you need to go to the ER or are admitted to the hospital,” says Loren Adler, associate director at the USC-Brookings Schaeffer Initiative for Health Policy at the University of Southern California in Los Angeles.
Of course, for some families it doesn’t take the rampage of the coronavirus for a medical situation to topple their finances. In September 2019, in Grass Valley, Calif., Bridget Brandstad’s 9-year-old son had three of his fingers accidentally crushed by a slammed door. The family rushed to the emergency room. While their plan had only a $500 ER fee, Brandstad says, the family wound up with bills from the hospital and doctor for nearly $2,000. They’re still paying in $50 installments. “I have to triage my bills every month,” she says.
Whether you face high healthcare costs because of the coronavirus or another medical condition, here’s what you can do to lower your financial risk.
STATES THAT HAVE EXPANDED MEDICAID
People in 36 states and the District of Columbia (shaded in the map below) are eligible for Medicaid if their monthly income is below $1,467 for a single person or $3,013 for a family of four. In other states, Medicaid is generally available only to people with children, with a median cutoff of about $8,700 per year for a family of three. To see about enrolling, go to healthcare.gov.
Source: The Kaiser Family Foundation.
If You’ve Lost Your Health Insurance
Given that about half of Americans get insurance through an employer, the huge numbers of people losing their jobs may suddenly find that they no longer have coverage, says Christen Linke Young, a fellow at USC-Brookings Schaeffer.
If that happens to you, time is of the essence because you don’t want to be caught uninsured during this period of high peril and because, in some cases, you must sign up for new insurance within 60 days of losing your job, Young says. Here are some options.
See whether you qualify for Medicaid. The ACA, passed in 2010 to provide insurance to more people, allowed states to expand their Medicaid programs, something 36 states and the District of Columbia have done (see map above).
In those locations, individuals with a monthly income of up to $1,467 and families with a monthly income of up to $3,013 qualify, according to the KFF. In other states, the annual median income limit for Medicaid is about $8,700 for a family of three.
To establish eligibility—based on current monthly income, not income before you lost your job—check with the Centers for Medicare & Medicaid Services (CMS), says Cheryl Fish-Parcham, director of access initiatives at Families USA, which helps consumers with health insurance problems. The rules vary by state, she says, and requirements may be different if you are pregnant, have children, or are disabled.
You can apply for Medicaid at any time after you lose employer-provided insurance. If you’re approved, coverage will begin on the date of application or the first day of the month you applied, according to the CMS.
Families with children under age 19 not covered by health insurance should look into CHIP—the Children’s Health Insurance Program. You can check eligibility here.
See if you qualify for a reduced-cost ACA plan. If your income is too high for Medicaid, you may still qualify for a subsidized ACA plan. Individuals who earn up to $51,040 and families of four that earn up to $104,800 get reduced rates on those plans. In 2019, 87 percent of people in ACA plans sold through the federal marketplace got subsidies and had an average monthly premium of $87.
In response to the crisis, 11 states and Washington, D.C., opened special enrollment periods during the spring so that uninsured people could sign up for an ACA plan to cover them for the rest of 2020. Previously, you could do this only if you experienced a qualifying event, such as job loss or divorce. Sign up at to healthcare.gov.
If you previously enrolled in an ACA plan and have experienced a loss of income, check to see whether you now qualify for a larger subsidy.
STATES THAT MADE IT EASIER TO ENROLL
In response to the COVID-19 crisis, 11 states and the District of Columbia (shaded in the map below) made it easier to sign up for an Affordable Care Act plan during the spring, not just during open enrollment in the fall or after a job loss or another qualifying event.
District of Columbia
Source: The Kaiser Family Foundation.
Consider COBRA. If you lose your insurance and worked for a government agency or company with more than 20 full-time employees, you must be offered an extension of your coverage under the Consolidated Omnibus Budget Reconciliation Act. But you will pay the full amount because your employer will no longer contribute to your monthly premiums. “That’s not great if you’ve just been laid off and have little money to pay for a premium,” Fish-Parcham says, “but if your healthcare needs are better served by remaining on the same plan, at least for a while, this is an option.”
The monthly cost varies widely but averages about $610 for an individual or $1,750 for a family, according to an analysis by USC-Brookings Schaeffer.
You’ll have 60 days to enroll after you lose your employer coverage. Ask your employer when coverage through your job ends so that you know when to sign up.
If You Have a High-Deductible Health Plan
In 2018, almost half of Americans insured through employers or an ACA plan had HDHPs. These policies tend to have lower monthly premiums but much higher deductibles. When a family faces big medical bills, HDHPs offer less financial protection.
The IRS defines an HDHP as one with a minimum deductible of $1,400 for an individual or $2,800 for a family. But on average, these deductibles can be much higher. For people with combined medical and pharmacy deductibles, the average is $2,114 for an individual or $4,250 for a family, according to a 2018 employer survey by the Pharmacy Benefit Management Institute, a research group.
For people who have ACA plans, deductibles can be even steeper: According to the KFF, deductibles for silver plans that include prescription drugs average $4,544 for an individual; bronze plans, $6,506. Among those who purchased insurance on their own (and not through a federal or state marketplace), two-thirds said that if they were hospitalized with the coronavirus they would be unable to pay their deductible all at once, according to a March 2020 survey by eHealth, an online marketplace where people can purchase private health insurance.
Although you can’t change the deductible once you sign up for a plan, you might be able to limit what you pay out of pocket, particularly if you need tests or treatments because of the coronavirus.
Find out whether drugs and treatments are covered before the deductible has been met. A 2019 federal rule allowed insurers to cover certain treatments before a deductible is met. The rule includes several common drugs, such as those used to treat high cholesterol or blood pressure, heart failure, osteoporosis, and asthma, as well as insulin for diabetes. Certain insurers have already implemented this change, and more may soon, says Brian Marcotte, CEO of Business Group on Health, an organization that helps large employers manage healthcare quality and cost.
Given the urgency of the pandemic, insurers have been able to adopt a similar rule to cover the coronavirus treatments before a deductible is met, says Loren Adler at USC-Brookings Schaeffer.
For example, Aetna announced in late March that it was waiving copays for people hospitalized at in-network facilities for COVID-19 treatment or related complications. Most Aetna employer plans will automatically offer this benefit, says Ethan Slavin, spokesperson for Aetna. Blue Cross Blue Shield, Cigna, and Humana have also said they will waive copays and cost-sharing for testing or treatment related to COVID-19 in some of their plans.
Use your Health Savings Account. An HSA, which allows you to sock away tax-free funds to pay for future medical expenses—up to $3,550 for an individual or up to $7,100 for a family per year—is one of the best ways to manage your healthcare costs. If you have one, you can use this money to pay for any qualifying medical service, including deductibles. You can also roll over unspent funds from year to year.
Shop around. For medical care that you can plan ahead for, shopping around can save you money because the price of medical services can vary substantially depending on the provider, says Maeve O'Meara, CEO at Castlight Health.
For example, a patient in Cleveland needing blood tests and an X-ray to screen for the coronavirus could pay as little as $241 or as much as $2,570 at different urgent care centers. In Dallas, someone could pay from $231 to $4,510.
SHOPPING FOR CARE TO LOWER COSTS
The cost of blood tests and exams needed to diagnose COVID-19 and rule out other infections can vary substantially among providers even in the same city. Shown here: Dallas.
Estimates for a person seeking care with moderate symptoms. ¹ 5th percentile. ² 95th percentile. Source: Castlight Health.
If You Get a Surprise Medical Bill
These are charges billed to you when you receive a service or treatment from a provider not in your insurer’s network. That can happen in emergencies, when you can’t always control where or from whom you get care.
That was the case for Melissa Janeiro of Lockhart, Texas, when she experienced complications during childbirth. She says she was told that the hospital was in-network, but it turned out that the anesthesiologist was not, nor were the providers in the neonatal intensive care unit. Janeiro received bills for more than $30,000. It took two years and the help of an attorney to get the bill down to $10,000.
About half of all states have enacted consumer protections against surprise medical bills, but only 13 provide comprehensive protections, according to an analysis for the Commonwealth Fund (PDF), a nonprofit health policy research group.
For almost a year Congress has been considering legislation to offer protection nationally, says Chuck Bell, programs director for advocacy at CR. Because COVID-19 treatments could be a big source of these bills, the need to address the problem is now even more urgent, Bell says. “In a slowing economy, people will have even less income and resources to deal with surprise medical bills,” he says. “The emerging COVID-19 public health crisis underscores the need for Congress to pass comprehensive legislation to fix this serious national problem.”
To avoid surprise bills, whenever possible find out ahead of time what providers your insurance does and does not cover. Should you still receive a bill, as Janeiro did, take these steps.
Hold off on paying the bill. Patients often receive bills from doctor’s offices, hospitals, and other providers before they are even sent to a person’s insurance company, says Caitlin Donovan, senior director for public relations at the Patient Advocate Foundation, which helps consumers with health insurance problems. When you get a bill, don’t pay it right away. Instead, Donovan says, “wait until you receive your explanation of benefits, or EOB. That will ensure that your insurer has received your provider’s claim and it hasn’t been sent straight to you.”
PROTECTION AGAINST SURPRISE MEDICAL BILLS
Thirteen states (shaded in the map below) have passed legislation that provides comprehensive protections against bills you receive from healthcare providers outside your network during medical emergencies.
Source: The Commonwealth Fund.
Make sure charges and coverage are correct. Donovan says fully half of all medical bills contain errors—lab tests you never had or providers you never saw, for example. Contact the provider or facility to point them out and ask for a revised bill. Also, confirm with your insurer what is considered in-network and out-of-network and whether the coverage decision was a mistake. It’s even worth asking whether your insurer will cover an out-of-network charge as an in-network service, Donovan says. “It never hurts to ask,” she adds.
Know your rights. Depending on the type of insurance you have, your state may have protections against surprise billing, Bell says. These either ban surprise billing outright or “hold consumers harmless,” so they aren’t responsible for the bill. But just because a state has banned surprise billing doesn’t mean you won’t receive a surprise bill anyway, Bell says, “so be prepared to fight.”
Negotiate with the provider and appeal to the insurer. If you’re stuck with an out-of-network charge, go on the offensive, Bell says.
Contact the provider and explain that your insurer is charging you the full out-of-network rate and you must pay entirely out of pocket. Ask whether the provider will charge you its discounted in-network rate instead, Donovan says.
Also, find out whether the hospital or provider offers any financial assistance, or if it will let you pay the charge over time, says Cheryl Fish-Parcham at Families USA. You can also ask whether it would consider offering a discount if you paid a lump sum.
If you can’t reach an agreement with the provider, appeal the insurer’s decision, Donovan says. You’ll want a letter that explains your situation, why you believe the insurer should cover your health problem, and if possible, why covering the cost now could prevent future medical expenses. Be advised that this can take up to 60 days for most employer-provided and ACA health plans.
If the appeal doesn’t work, you can request a review by a third party, Donovan says. The insurer is required to send you information on how to initiate the process.
Get help. If you’re still having trouble after appealing to the insurer, you can contact your state’s consumer assistance program, if it has one, or insurance department. Go to HealthCare.gov’s Find Local Help page for more details. Also, contact the Patient Advocate Foundation for help (or call 800-532-5274, 8:30 a.m. to 5 p.m. ET Monday through Thursday).
Editor’s Note: This article also appeared in the June 2020 issue of Consumer Reports magazine.
Source-Consumer Reports -April 2020