Having access to affordable health insurance can protect you from financial hardship if you are diagnosed with a serious medical condition. It can also help you avoid costly delays in getting care and preventive services that could worsen your health. However, a recent survey found that many people with health coverage struggle to afford their health care costs. Nearly three in 10 people with employer plans, more than one-third of those in marketplace or individual-market plans, and two-fifths of those with Medicare reported that they or a family member delayed or skipped needed health care or prescription drugs because of cost.
The costs of health care can vary based on the type of service and the provider, but all health plans have some kind of cost-sharing arrangement. These costs are deducted from the total cost of your care and can include a deductible, co-pays, and/or co-insurance.
A deductible is the amount you must pay each year before your health plan starts paying for some services. A deductible can apply to prescription drugs, hospital stays, and out-of-network care. Some health plans have a flat deductible, while others have a tiered deductible that increases as you meet certain spending thresholds.
Out-of-network costs are when you receive care from doctors, hospitals, and other providers who are not part of your health plan’s network. Generally, out-of-network care is more expensive than in-network care. Some health plans have limits on out-of-network care, and some only cover emergency situations outside the network.
Your health plan may review your medical bills to decide if the service or procedure is “medically necessary.” If the health plan decides the service is not necessary, it will deny or reduce payment. This is called utilization review.
If your claim is denied, you have the right to file an appeal within a specific time period (which varies by state). Your health care provider can also submit information supporting why the service or procedure should be covered.
If you lose your job or your company discontinues offering group health benefits, you can purchase individual coverage through the private market or through a government-sponsored program like Medicaid. You can also keep your current health insurance through a program like COBRA, which allows workers to continue coverage that would otherwise end if their job or hours are cut, for up to 18 months. It is important to act quickly to sign up for COBRA or another source of coverage so that you don’t have a gap in coverage.