Opinion

Avoiding Health Care Horrors During Open Enrollment

By Jason Resendez
November 19, 2019 at 5:00 am ET

Understanding what your health insurance covers is essential to avoiding major pitfalls that can cost consumers money. After all, making the wrong health care decisions can have serious and long-lasting repercussions for patients and their families. 

A new survey from Consumers for Quality Care conducted by Morning Consult finds that consumers are largely unsure what their insurance plans cover. With health insurance open enrollment underway, this new data underscores the need for our health care system to be more transparent about costs and coverage to help consumers avoid unneeded nightmares.

What we found is frightening. Only 51 percent of respondents said they understand very well what their insurance covers for the most common of medical events: a routine doctor visit. That number drops precipitously with other types of insurance uses; only 32 percent understand very well what their health insurance covers for in-network hospital services.

Only 22 percent understand very well what is covered for out-of-network hospital services or what is covered if they are in a car crash or other type of accident. Overwhelmingly, consumers are unsure about what’s under the hood when it comes to their insurance plans.

Whether consumers have health insurance through their employer, Healthcare.gov, Medicare or another source, open enrollment season is the one opportunity they have each year to review and change their coverage. Knowing what to look for can help health care consumers make better choices.

As advocates for consumers, CQC urges Americans to understand and watch out for policies and procedures that can result in increased costs and coverage denials, including health care horrors like surprise medical bills, short-term, limited-duration insurance plans and policies that prevent the coupons Americans use for their medication from counting toward deductibles or caps on total out-of-pocket costs.

We expect that our health care premiums will cover most of our hospital costs, but according to the CQC survey, 35 percent of voters say they or a loved one has received a surprise medical bill. Stories of patients hit with surprise hospital bills are proliferating across the country. In Virginia, a woman visited the emergency room for abdominal pain after doing all her research to confirm the emergency room she went to was listed in network, but she still received a surprise bill of more than $1,000 when one of the attending physicians was out of network.

Even scarier are short-term, limited-duration insurance plans, which can exclude coverage for pre-existing conditions, have dollar value limits on covered services and are not required to cover preventive services. These “junk plans” pass unanticipated costs along to consumers, leaving patients who thought they had coverage without a safety net when serious medical issues arise.

One example was an Arizona man who suffered a massive heart attack and fully expected to pay his $7,500 deductible for surgery and hospital care. Unfortunately, when a bill arrived for nearly $250,000, he learned that his short-term, limited-duration insurance plan would only cover about $4,000 of the expenses. Last year, the Trump administration issued a rule expanding the maximum period for which STLDI plans can be offered for up to 12 months, causing these barebones plans to proliferate.

Another Trump administration policy putting the spooks into consumers are limited accumulator adjustment programs that limit the value of drug coupons counting toward a patient’s deductibles and out‐of‐pocket caps. This could lead to more patients exploring options such as taking their medication every other day, going into credit card debt paying co-pays for medications that were previously affordable with co-pay assistance, or halting taking needed medications altogether.

Consumers are fed up with the lack of transparency and the lack of certainty around costs. The CQC survey found that the vast majority of respondents — 87 percent — agree that insurance should work like insurance again and actually cover people when they get sick, and they are looking to lawmakers, insurers, drug companies and hospitals for help.

Until things change, it’s up to consumers to use the open‐enrollment period to educate and empower themselves to make the best decisions they can when it comes to their health care coverage.

 

Jason Resendez is a Consumers for Quality Care board member and health care strategist.

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