If you are reading this article, you are probably worried about a medical or hospital bill that you will find challenging, or even impossible, to pay.  It is no great comfort to know that you are not alone. Every year thousands of Americans find themselves in the same position.

Our first three pieces of advice are:

  1. Don’t panic
  2. Take action now but
  3. READ THIS ARTICLE first!

Of course, there are many reasons for finding oneself in the position of struggling to pay bills associated with healthcare. They fall into three main categories:

  1. Elective treatment

Your chosen Hospital (Clinic or Health Center) may well be part of your insurer’s network, but they cannot guarantee that everyone in the team of ‘providers’ committed to your treatment is also in-network.  

Each member of the team will be paid the agreed network fee for their part in the procedure.  Their scale of fees may be far above that. They are quite entitled to charge you for the ‘balance.’ This is an example of ‘surprise’ medical billing*. It may have come as a surprise to you!!  At least it explains what balance payments are.  An out-of-network anesthetist can, on average, charge 5x as much, a diagnostic radiotherapist 4x as much, as the rate paid for similar services by Medicare

  1. Emergency treatment

Most emergencies are sudden illnesses, for example, a heart attack or an accident.  Most often, these occur in the home or the workplace.  BUT inevitably, you may be visiting, out of state, on holiday.  In these circumstances,  you may not have any choice of service providers. The nearest suitable hospital, the first available ambulance, may not be in your insurance network.  Your insurance company is obliged to meet the terms of your plan but only up to their agreed in-network limit – one in five visits to ER results in ‘surprise’ medical billing.

  1. Change in financial circumstance

You may have experienced some critical change in your financial circumstances impacting your ability to maintain your premium payments. In such cases, such as the loss or enforced change of jobs, it is possible to apply for a personal Special Enrollment Period (SEP).  An SEP provides you with the opportunity to re-assess your health insurance plan.

*For a fuller description of ‘Surprise’ billing, see the TrueCoverage article, when is a surprise not a surprise?’

Now, what should I  do?

First, you need to read the letter or letters that came with the payment requests very carefully. 

If you were expecting your insurers to meet your costs, you should find out who sent the bill to you and why.  If you purchased your plan through the marketplace, you should contact them.  First, keep them informed, and secondly, take advantage of their expertise. 

Perhaps you received the bill because you are overdue with your monthly premiums.  Make sure you bring them up-to-date as soon as possible or arrange to delay or adjust your payments.

If your employer normally pays your health insurance, you must contact the scheme coordinator to determine why the premium has not been paid.  If your employer has gone out of business for reasons covered by a state of emergency, you may have some protection under the relevant emergency legislation.

The unpaid amount may result from a surprise billing (described officially as “balance” billing).  Well over half the States have legislation to protect their citizens from balance billing.  Talk to your insurance broker, your insurer, or your state department of insurance to ensure you have the protection you are entitled to.  While the American Recovery Program Act (ARPA) is in effect, the ACA  addresses this situation by prohibiting health plans from requiring members to obtain pre-authorization from their insurers for emergency services. Providers are not allowed to charge higher co-pays for out-of-network emergency services.  

Second, you must consider the implications of having to pay some or all of the outstanding amount.  Not resolving the issue as quickly as possible could affect your credit score and your relationship with other lenders, for example, your bank and credit card companies. 

When contacting any of these organizations, be prepared to explain 

  • Your financial and employment position
  • How much you can afford to pay
  • When you will be able to restart regular payments (if appropriate)

And be prepared to discuss your income, expenses, and assets.

Third, if your household’s financial circumstances have changed considerably,  you may be eligible for Medicaid.  This federal program offers free ACA-compliant health insurance for you and your dependents.

OUR FINAL ADVICE is the same as the first. Discuss your circumstances with your employer, insurance company, or your chosen Health Insurance Marketplace.

Most of your options are time-sensitive, so please, act now!