Health Insurance Options & Negotiating Medical Bills (USA only)

As with the whole website these notes are for me if it helps you great. I am not a doctor, lawyer, financial or tax advisor. So please take everything that follows carefully and consult an appropriate person before following any of this advice.

Contents

Health Insurance Plan Options

Types of Plans available
- HDHP High deductible health plan
- EPO exclusive provider organization EPO is essentially a strict HMO plan
- PPO
- HMO
- Health Share Ministeries
Understand your plans by comparing the following (bolded ones are important)
- Premiums
- Deductible – individual vs family
- Coinsurance
- Tax Breaks, for example, HSA for HDHP plans or if your employer contributed to your HSA plans!
- What specialty services like physical therapy and at what limits are covered by a plan and also whether you need a primary care doctor referral to see a specialist
- Out of network coverage?
- For items that you are likely to use what is the deductible and whats the copayment and coinsurance
- Are the doctors you prefer in-network?
- Are there any specific life events (e.g. having a baby) that may increase your healthcare utilization?
- Are specific members of your family more likely to use healthcare than others? Individual vs family deductibles
- If you have some major health issues or an accident, what would be the maximum you would have to pay?
Some people either take up a part-time job or take a course in college (depends on college) to get better health insurance terms
Health Share Ministeries (are not legally responsible or regulated to provide coverage)
- If you develop a chronic condition such as diabetes then will only cover up to a certain time for example 6 months
  - Insurance retail price of diabetes insulins is 1k per month
  - Canada around 200 per month!
- Sometimes they do not cover pre-existing conditions
- Often a lot cheaper than traditional health insurance and can request a cash discount from the provider
- Usually religious organization
- Best if you do not have a pre-existing health condition and also do not have significant assets.
- Might deny coverage if you have a catastrophic life situation will bills exceeding 100K!
If you are paying health insurance premiums through payroll deduction they premiums are pre-tax
some health insurance plans require a referral from primary care doc to refer to a specialist or for a specific treatment – mostly EPO plans
Prior authorization from health insurance companies is different from a referral. For example, if you are going to have a procedure the doctor doing surgery ca as for prior authorization from the insurance company on whether they procedure id covered or not
Make sure you understand the difference between a per person deductible and a family deductible
Sometimes HDHP out of pockets max could be lower than PPO
Sometimes deductible is equal to out of pocket max.
Some employes usually the federal and state government may provide continued health insurance after retirement

Health Insurance Coverage

Make sure you have a plan with an out of pocket max since it shields you from a bill in the range of 50K to 1M
Since even, a 20% coinsurance with an out of pocket max with a 1M bill can give you a bill of 200K
When you have a baby, it means an additional individual …a separate deductible for the baby once they are born
InPatient means you are admitted to a hospital and will probably spend on a night
Out-Patient means you are visiting a hospital
When you are admitted in a hospital be careful
- Anesthesiology, radiologist, pathologist (lab) and lab work could be out of network …you can try to send them in-network but it depends on you.
- Also if you are easily able to do all these things on your own otherwise hospital might charge extra and facility fee
In-Network vs Out of Network
- Note that when you go to a hospital…some services could be in-network and some out of network! Very confusing especially with all the stress of being in a hospital
- Recent Texas law cracked down on surprise billing from out of network providers
Before going to any doctor or any lab make sure to call beforehand to find out whether it is in-network or out of network
know the place of service …Office Visit vs Urgent Care vs ER vs Free-standing ER

Emergency Room’s (ER) tips

In texas, freestanding ERs are usually out of network
be careful with going to doctor thinking it is urgent care and only late you find out that it was an ER
In a real emergency, it is better to go to ERs which are connected with the hospital rather than these freestanding ERs
Also, Freestanding ERs might not have all the equipment you might need so they will transfer you to an actual hospital
you can never know when there will be an emergency so it is better to talk to your health insurance company and know which ERs close by are in-network
Ambulances are useful but the costs are prohibitive like 5k-10K so take the ambulance ride when you think it is a true emergency
When you call 911
- You can refuse transport to an ER if you are thinking clearly and not unconscious
- You also have the option to tell them which ER you want to go to
- They can choose to be default the nearest ER

COBRA

COBRA might be an option when you leave your job
You have 60 days to elect COBRA coverage
Health insurance premium might be more expensive since your employer might be subsidizing your health insurance premiums
TIP: COBRA premiums can be paid from your HSA balance!
You may be able to use COBRA for 18 months
Surviving spouses for 36 months for COBRA
MORE RESEARCH NEEDED FOR THIS SECTION

Negotiating Medical Bills

The process of how you get bills when using health insurance
1. Hospital or doctor office send the claim to the insurance company
2. The insurance company then processes the claim and sends the details and explanation of benefits (EOB) to you. EOB also mentions how much you might owe like reduced charges, co-pay or deductible
3. Then you get the bill in the mail from the doctor’s office or hospital. It is usually delayed by 1-2 months.
  So best is to keep notes on your doctor’s visit while it is still fresh in your mind!
if you are getting a bill from the hospital you can also ask for the itemized bill
Look for duplicate charges
Look for charges for services that were not offered. In my experience 20% of the time, you will find services which were not offered.
The facility bill from the hospital could be a lot. Let’s say they took a CT scan or MRI and the cost will be let’s say 5000$…if you will look in itemized bill details it could be 1500 for the procedure and 3500 is the facility fee.
Negotiated discounts by health insurance companies are still a lot
Cash pay discount, For example, say an allergy test is $595 rather than it runs through insurance the same thing is $1200
MDsave is a good website if you have a requisition form from your doctor you can shop around which CAT scan, MRI scan facility you want to use especially if you have a high deductible
Large hospitals can give you discounts when you ask for it. Say you want to pay everything in one go and they can easily knock off 15-20% of the bill.

Asset protection from Medical Bills

In case you have to declare bankruptcy due to medical bills
- 401ks are protected in every state since they are regulated federally
- IRAs are regulated at the state level. They are protected in Texas.
- House is protected in texas

Medicare Medicaid

Medicare is for people who are 65 years or older or have a certain disability
- Still costs money for premiums, deductible, and copays
- Limited coverage (e.g. will not cover at-home nursing care or nursing home facility)
- Medicare part a is free
- doctor visits and out patent visits are covered with part d
Medicaid is governed at the state level for older people and muse meet specific income and asset requirements or categorical requirements (e.g. pregnancy or disability)
- Usually covers a fair amount of medical expenses and often the only option for nursing home care
MORE RESEARCH NEEDED FOR THIS SECTION

Miscellaneous

Medical id on iPhone
Legalzoom for power attorney
Texas allows a cap on medical malpractice