Insurance policies like high-deductible plans, broadly offering skimpy short-term, limited duration insurance (STLDI) plans, surprise medical bills, prior authorization protocols that allow for dangerously delayed and misguided decisions on prior authorization requests and emergency department denials after-the-fact are major contributors to rising out-of-pocket health care costs and uncertainty.
CQC-Ipsos research shows that two in three Americans struggle with predicting how much they will have to pay for health care when they need it. They fear health care costs even more than they worry about costs associated with retirement, college, housing or childcare. And with the continuing trend of ever-higher-deductible health plans, the proliferation of short-term, limited-duration insurance, after-the-fact emergency department denials and misguided prior authorization protocols, the only thing many consumers can predict about their out-of-pocket health care costs is that they are going up.
Too many insurance practices are pushing more and more costs onto consumers. Nearly one in four covered employees have a single-person deductible of $2,000 or more. While these lower-cost, higher risk plans work for some, consumers who can least afford catastrophic costs associated with accidents or chronic disease are those most likely to be attracted to the lower premiums then get debilitated by the high out-of-pocket costs, or forego needed care.
Short-term limited-duration insurance (STLDI) plans are also passing unanticipated costs along to consumers. STLDI plans are exempt from many Affordable Care Act (ACA) requirements and can exclude coverage for preexisting conditions – including conditions an individual did not know they had or were not aware required medical intervention – have dollar value limits on covered services, are not required to cover preventive services, and have a host of other substantial risks for consumers. Allowing these plans to continue for 12 months or longer places people in these plans with significant financial risk, and recent research conducted by Ipsos on behalf of Consumers for Quality Care (CQC) found that 64 percent of Americans prefer policies that require all health plans to cover essential health benefits than those that ban plans that charge more based on sex, health status, age, or deny pre-existing conditions. Last year, the Trump administration issued a rule expanding the maximum period for which STLDI plans can be offered, causing these barebones plans to proliferate.
Prior authorization of medical treatments is also a common fixture in modern health insurance plans, intended to control costs to make insurance more affordable. Unfortunately, significant delays and dangerous denials are also all too common. An American Medical Association (AMA) survey of 1,000 physicians found that 9 in 10 reported prior authorizations delayed access to necessary care and more than 25 percent said the delays had led to a serious adverse event. Out-and-out denials force patients into a gut-wrenching choice between two grim options: forgo needed treatment or medications or pay exorbitant amounts out-of-pocket. Even if an insurance company has an appeals process, it can take several requests and time and money some patients don’t have before the drug or treatment is approved – if it gets approved at all.
Finally, some insurers are instituting policies that would force policy holders to pay for an emergency room visit if the insurer later deems it a non-emergency. These policies, which essentially require patients to diagnose themselves in order to ensure their condition is serious enough to be deemed an emergency by their health insurer, are harming customers while reducing costs for the insurers implementing them.
Real-life #insurancefail examples:
High-deductible plans are forcing more and more consumers to delay needed care due to cost. One consumer discovered she carries a genetic mutation that increases her risk of breast cancer to 72 percent. Her doctor recommended annual mammograms and MRI breast scans, but her $6,000 deductible put these tests out of her price range. She decided to delay her second-year screenings until she was able to pay off the debt from the first round. These plans are also putting stress on families who don’t have enough income to afford the high deductibles of the plans. Andrew Holko is a 45-year-old father of two who is facing thousands of dollars in outstanding medical debt because his family is unable to afford treatment with their high-deductible plan.
Consumers who are seeking lower premiums often don’t realize short-term, limited-duration health plans may not protect them when they are sick, leaving them with large surprise bills for uncovered care. That was the case when Charlie Butler was diagnosed with testicular cancer. He believed that his health insurance, an 11-month STLDI plan through National Brokers of America Inc., would help cover the cost of his care. Instead of paying the tens of thousands in medical bills for Butler’s treatment and care, his insurance canceled his plan, citing a preexisting medical condition even though the diagnosis came after he purchased the plan.
Heartbreaking stories abound detailing insured patients struggling to access the treatments their doctors order. Blue Cross Blue Shield denied a St. Louis man’s lung cancer treatment after he lost his left lung to the disease. Fidelis refused to cover a life-saving bone marrow transplant for an infant born with a genetic disorder leaving him with virtually no immune system. Significant delays in scan and drug approvals for 25-year-old Colin Haller led to him ultimately succumbing to metastatic melanoma. These stories are even more heartbreaking in light of recent testimony from an Aetna medical director that he did not review patients’ medical records before denying their claims.
As part of Consumers for Quality Care’s #HealthCareFail campaign, consumers from around the country are sharing videos with us where they explain their experiences with the health care system in their own words. Michelle from Florida shared her story about needing to fight with her insurer to get her doctor-prescribed medication covered. After her insurer stopped covering her Lupus medication, Amber from Texas saw her symptoms flare up and is still feeling the effects a year later.
Emergency Department Denials
In Missouri, Sandra Rivera, who underwent a previous heart operation with some complications, went to the emergency room after waking up with chest pain and heart palpitations. Fortunately, she did not have a heart attack, but Anthem sent her a letter informing her this visit would be covered, but any subsequent visits with similar symptoms would not be. Rivera is understandably worried about the next time she may experience similar symptoms and the choice she will have to make in trying to avoid a bill.
In Frankfort, Kentucky, Brittany Cloyd went to the hospital with a fever and strong pain on the right side of her stomach at the advice of her mother, a former nurse, who suggested it might be appendicitis. It turned out Cloyd had ovarian cysts and Anthem denied the $12,596 bill, leaving her to cover the full sum.
An Illinois mother shared her story with emergency department denials as part of CQC’s #HealthCareFail campaign. After taking her son to the emergency room for breathing problems, she was shocked to find out that her insurer wouldn’t cover any part of the visit.
What you can do:
Unfortunately, high-deductible plans appear to be here to stay. Nearly half of covered private sector-workers had high-deductible plans in 2018, and nearly one quarter of large, self-insured employers offer a high-deductible health plan as the only insurance option for their employees. Before selecting a high deductible plan, make sure you know what your plan covers and make sure you have a plan in place should you or a loved one has an accident or gets diagnosed with an acute or chronic illness that requires you to meet your deductible.
Every year during open enrollment, consumers have an opportunity to choose their health care plan for the upcoming year. While bare-bones STLDI plans may appear less expensive, we urge consumers to steer clear of these plans that can leave patients with large surprise bills for uncovered care. While some states have imposed limits on these plans, most lack comprehensive, essential coverage like maternity care or mental health treatment and allow insurers to deny coverage based on preexisting conditions. It is important for health care consumers to read the fine print and consider their options carefully.
Likewise, not appealing prior authorization denials is a missed opportunity. A recent Kaiser Family Foundation report found that in 2017, 121 major health insurance issuers denied a total of more than 42 million claims. Consumers appealed less than 200,000 (0.05%) of these denials. Furthermore, although consumers have the right to bypass their insurer’s internal appeals process and go directly to an external review with the State Insurance Commissioner’s office, this happens in fewer than 1 in 11,000 denied claims (0.009%). Contact information for State Insurance Commissioners can be found here.
Emergency Department Denials
Insurers need to step up to the plate and to do what’s right for patients and families. Until they do, consumers should note which insurance companies are implementing policies that allow for ED denials after-the-fact, and in which states. Anthem Blue Cross/Blue Shield is the insurer that appears to be following through on this policy the most. If you select a plan with this policy in place and encounter issues with emergency department coverage, many of the affected states have established hotlines through their insurance commissioners to file complaints.
We know these denials have occurred in Georgia, Indiana, Kentucky, Missouri, New Hampshire and Ohio, and likely other states as well. If you encounter an issue with an emergency department denial, your best first step is to contact your state’s insurance commissioner. Contact information for insurance commissioners in these states can be found here.
Notably, insurers have overturned many ED coverage denials when pressed, so we encourage consumers to appeal. However, patients should not be forced to deal with red tape and bureaucratic appeals to get the coverage they already pay for.
58: Percent of Americans who find it frustrating when insurance does not cover emergency room or urgent care visits.