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STUDENT TALK How do I deal with US healthcare?

Authored By: Nathan Liang on 8/2/2021

As a transgender person in the United States, I’ve found the medical transition process to be a double-edged sword. (Important side note: You do not have to medically transition to be valid in your trans identity!) Out of necessity, I’ve become fluent in the navigation of the labyrinth that is our healthcare system. Why? Because in order to get the appropriate care, I discovered it involved a lot of hands on, constant work. I can’t tell you how many hours I’ve spent on customer service calls with insurance companies, hospital billing centers, doctor’s offices, and CVS just to make sure my needs have been met and adequately cared for. There are multiple good sides in this mountain of work, I made it through, and I've got some wisdom to share, that may assist you on the same or simliar medically and administratively complex odysseys.

Basics of Health Insurance

Health insurance policies, like people, come in a vast variety. They include many confusing terms, and not all companies use the same terminology. Why? From what I can gather, "just because they can." The following terms are pretty consistent regardless of which type of policy you're discussing:

  • Premium: The amount you pay monthly for your coverage. Higher monthly premiums typically mean your insurance company covers more of your care.

  • Deductible: The amount you have to pay out-of-pocket before your insurance company pays for anything. Basically "your share" of the expense. It's not an up front cost, but instead represents the cost of care you have to pay before your insurance kicks in. For example, if your deductible is $300, you can pay it off with a $120 routine check-up, $80 of prescriptions, and a $100 blood test. If you had a procedure that cost $1000, the $300 deductible would apply first. Your insurance would then help you cover the remaining $700 according to the policy's limitations. Paying your deductible doesn't mean insurance pays everything from there on out. Depending on your coverage, you may pay 20%, 40%, or none at all. Each policy is different, and it's important to know what yours requires.

  • Co-payment: A flat fee you pay for covered care. For example, if you go in for a routine check-up, you pay $20, and then the insurance company will pay the rest of the bill.

  • Co-insurance: A percentage of your covered care required to be paid by you (vs the flat fee mentioned above), and then your insurance company covers the rest. 

  • Out-of-pocket maximum: The annual amount you have to pay for covered care before your insurance company covers 100% of your care.

  • Claim: A request submitted as proof of service/care letting the insurance company know you need to be reimbursed, or a bill needs to be paid. Most of the time, it will be your provider that submits the claims so they can get paid. But if you pay out of pocket, don't forget to submit for funds you are entitle to.

  • In-network provider: In-network providers should be a focus in terms of coverage. These providers are contracted by the insurance company to provide care for their enrolled patients. This means the insurance company will cover (partially or in full) the care you can get from that provider. Preventative care is usually free from in-network providers. It's also easier to manage insurance issues with in-network providers. Still, you’re not limited to in-network for your care but realize you may end up paying more, and in some cases ALL of your care with an out-of-network provider.

  • Out-of-network provider: If you need care from an out-of-network provider, your insurance company may not cover the resulting medical bills. But, depending on your insurance plan, your doctor/service provider can submit a claim and see if the insurance company will cover at least a portion of the bill. Although in my experience, the answer tends to be no coverage at all. But if it's care you want, and you can pay, there is nothing preventing you from seeking care outside the network. 

Of course, the exact price and effect of these terms will vary depending on the insurance company, type of plan, and how much you’re willing to pay. A good way to compare different plans is to look at a side by side cost comparison for care you anticipate needing. If you have a significant other who also is eligible for health insurance, consider doing a side by side comparison with that coverage as well. Sometimes it's less expensive, and you get better coverage using the family or partner plans offered. One infamous detail of MIT’s health insurance plan is that it does not cover dental care for undergrads. Read more about the different types of insurance plans.

Dealing with High Out-of-Pocket Costs

High out-of-pocket costs can result when your insurance doesn't cover a specific procedure, or when you have a high deductible to be paid before insurance kicks in. This can be an extremely frustrating thing to deal with, especially when you’re a poor student like me. Make sure to check your insurance policy to be forewarned if you're looking at some large planned medical expenses. Here are a few options for dealing with insane out-of-pocket costs.

Charity Care

This is healthcare provided for free or at a reduced cost for lower-income patients. This requires you to shop around for a provider offering this option and actually asking them if they offer reduced or free care based on need. Make sure to do your research and ask for referrals from your current providers. You might discover the provider you're using offers charity care for the services you’re looking for. It's usually just a simple form to complete, and in fact, a number of hospitals offer this type of option.

Crowdfunding

You’ve probably seen success stories of people raising money for life-saving surgeries and medical treatments on GoFundMe. I used it myself when I had to deal with a surprise medical bill that I hadn’t planned for. If you believe in the power of community fundraising, it doesn’t hurt to try it out. You may just receive enough funds to help you through a tough time.

Grants and Similar Resources

There are also medical grants and sponsored programs that provide financial aid for those who cannot afford the care they need. There are some government-sponsored programs such as Medicaid and Medicare, but you can also find organizations that specifically support marginalized communities. For example, PointofPride, run by trans activist Aydian Dowling, provides support funds for trans people seeking transition-related financial aid. S^3 (Student Support Services) and the ARM (Accessing Resources at MIT) Coalition also provide financial support and resources for MIT students.

Health Savings Account (HSA)

If you’re on a high-deductible health plan (HDHP), you may be able to enroll in a Health Savings Account  (HSA), which is exactly what it sounds like. This might be a longer-term option since you will have to build up the value in your HSA, but the money can grow tax-free in the account. Several local banks and credit unions offer HSAs, so check with your current financial institution. Consider it a savings plan for specific medical procedures, or your tax-free emergency fund for health costs.

Medical Loans

Like any large purchase, you can also take out a loan to help you out with medical expenses.  Loans add a whole new flavor to taking care of medical expenses. It pays to understand what you're getting into. In most cases, borrowing money with a personal loan can be the most expensive way to cover costs. But they can sometimes be a way to get funds quickly. MIT Federal Credit Union offers a personal loan that can cover these types of costs.

Request a Payment Plan

You can also request a payment plan from your provider. Some providers use sliding scales to adjust your payment based on your income. You can also request an interest-free payment plan if you find yourself especially strapped for finances.

My Enemy, The Medical Bill (and How to Vanquish Them)

Medical bills, especially for more invasive and expensive procedures, can feel daunting to comprehend and confront. As of this writing, I’m still dealing with a bill for a surgery I had last May because of a misunderstanding and a clerical error with billing. Understanding what can be involved may assist in avoiding any surprises.

Pre-approval for procedures and testing

Certain procedures require pre-approval from insurance. Make sure you get that pre-approval in writing before walking into the procedure room. This pre-approval can even extend to routine testing, and sometimes your provider doesn't volunteer information regarding the need for pre-approval, so always check with your provider and your insurance about all the logistics to guarantee payment. Otherwise, you may end up having to foot the bill. Also, ask them whether there will be an upfront deposit. Depending on where you live, a third-party provider, like a diagnostic center, may require a portion of the total bill ahead of time, sometimes as much as 50%, even if your insurance provider will pay later.

The Bill Itself

It’s really important to do your research. Get an idea of the price range for your procedure. You can do this with a dedicated Google search and/or calling different service providers and asking for price estimates. If the bill you get isn’t itemized, ask to get an itemized version. People have found duplicate or nonsensical charges this way. It’s also good to make a note of everyone that provided you care because you may get a separate bill from each provider. For example, when I got top surgery, I was charged one bill from the surgeon, one bill from the hospital, and one bill from the anesthesiologist. This is not uncommon for surgeries or procedures requiring diagnostics or anesthesia, and those bills arrive at different times. Just make certain to track them all, and if one seems to be missing, call and find out where it is.

Collections

This is when your medical provider (or whoever handles billing for them) sends the bill to a debt collector. This will usually happen if no payment has been made after a length of time. Sometimes there is a given timeframe, 6 months or a year. After that timeframe, which varies between providers, they contract a debt collector to aggressively pursue payment of the bill. Unfortunately, someimes this even happens if you've agreed to a payment plan. If this happens to you, talk to your medical provider to find out of this was a mistake. Some bills automatically get forwarded even when a plan is in place, but they can "call off the collectors." Communication is key in resolving these things. The most important thing? Don't ignore calls from a collector. It can have consequences.

Consequences of Not Paying

If your bill went to collections for non-payment and there was no payment plan in place, you need to find a way to pay the bill off as soon as possible. If the debt collector holds onto your bill for long enough, they will report the medical debt to the credit bureaus. At that point, your credit score will take a hit. The larger the bill, the more your score can tank. And while that one item may seem inconsequential, if you’re trying to buy a house down the line, it can hold up a closing, and you will be required to pay it in full as part of your closing, even if the debt was written off by the hospital or provider. Even a small bill placed in collection and subsequently written off for non-payment can have repercussions months or even a few years later.

How to Advocate for Yourself

The most important thing to keep in mind is that you have rights as a patient. Unfortunately, my experiences gave me a rather cynical view of the US’s for-profit healthcare system. On the other hand, it’s also emboldened me to take action when I feel I’m being treated unfairly.

If something doesn’t look right, call all relevant parties. If you don’t have the energy to immediately confront the matter, have someone you trust help you through the process. But don't ignore it. You can designate them as your health care/patient advocate, or you can find third party services that will provide you with an advocate. The advocate's job is to literally advocate for you through every step of the process and make sure you’re not being scammed or discriminated against. MIT Medical has this in the form of a patient relations coordinator.

If you’d rather detach yourself from the situation altogether to decompress and redress the situation later, that's always an option. My only warning is that healthcare administrative processes can be slow-moving. It’s always better to act sooner rather than later. 

And don't forget! As a patient, you have rights! Don’t be afraid to call insurance companies and hospitals when you feel like the bill looks too high or includes an error or strange fee. Advocating for yourself and informing yourself is the best thing you can do to ensure you’re treated fairly.

Sources



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