This post is for folks living and dealing with healthcare in the United States – especially those of you who are learning about health insurance for the first time, are in a tough spot financially, are chronically ill, under-insured, or all of the above. I’ve never had the opportunity to live abroad, so I have zero experience with the wild (and amazing?) concept of universal healthcare. In the US, my healthcare experience has spanned from being uninsured to having the best-of-the-best employee health plans. It wasn’t until recently, as someone with chronic conditions who works freelance, that I’ve had to venture deep into the nitty gritty of how US-based health insurance actually works – appeals, grievances, and all the tips and tricks to lower my ridiculously high medical costs, despite having insurance.

The following post is the culmination of 20 years of my varied health insurance experiences. It’s my hope that gathering all of this info – along with a few tips on how to deal with insurance companies and medical providers – will help others. Whether you’re someone figuring out your healthcare options for the first time, someone that suddenly needs more access to healthcare than before, or anywhere in between: here are some general definitions, resources, and tips that might give you a hand.

Disclaimer: I’m not a healthcare professional! The following tips come from my own experience. What works for me may not work for you, although I hope it does. Be sure to carefully review your own health insurance policy to confirm your coverage. Also, this post is focused solely on private health insurance. Private health insurance differs from Medicaid and Medicare, which are federal programs that provide health coverage for those that meet certain income requirements (Medicaid) or are over the age of 65 (Medicare). Resources for Medicaid can be found here and resources for Medicare can be found here. Last, there are a variety of other forms of insurance that touch on your heath but are not specifically health insurance (life, disability, etc.). Those plans will not be covered in this post.

Ok let’s go: Health Insurance 101

Basic insurance terms and their definitions

Health Insurance: a method of paying for health care

Types of Insurance: Health, Vision, Dental, Prescription – do NOT assume that one health care plan covers all of these areas. Most individuals have plans for all.

Terms pertaining to the financial side of health insurance

Premium: the flat monthly fee an individual pays for their health insurance plan. If you are an employee with access to health care, your premium is often deducted from your paycheck. If you are self-employed, unemployed, or employed without access to healthcare, you will pay your premium on your own.

Deductible: the amount of money an individual pays out of pocket before their insurance begins paying for services. The deductible amount varies across plans. I’ve seen deductibles range from $0 to $17,000. Typically, a high deductible translates to a lower monthly premium and vice-versa. Deductibles are in addition to your premiums and they reset annually.

Co-Insurance: the percentage of medical costs an individual is responsible for after they have paid enough out of pocket to meet their deductible. The insurance provider is responsible for the rest. For example, if you are responsible for 20% Co-Insurance, your insurance provider is responsible for 80%. Co-Insurance varies across plans (it’s frequently 20%, but not always – mine is 50%). Individuals are responsible for co-insurance until they meet their Out of Pocket Maximum.

Out of Pocket Maximum: the most an individual will pay in a calendar year for their covered health expenses. Once an individual hits their Out of Pocket Max, their insurance company will pay 100% of covered costs.

Co-Pay: a flat fee that an individual will pay to visit a doctor, independent of a deductible. Some plans have copays, others do not.

Terms pertaining to your coverage

Covered Service: services, supplies, drugs, etc. that a health insurance plan WILL pay for, subject to deductible and co-insurance. There are many services that an insurance plan will NOT cover at all – common services not covered are (but not limited to): weight loss treatments or treatments deemed experimental.

Allowable Amount (also “eligible expense” or “negotiated rate”): an agreed upon cost for a medical service. This agreement happens between your insurance provider and your medical provider. It is common for a medical provider (doctor, lab, clinic, etc.) to bill well above the Allowable Amount. Your insurance company will prepare an EOB showing the billed amount and the Allowable Amount. Often, the difference between the two amounts is written off – no one pays it. However, that is not always the case – sometimes individuals are responsible for the difference. In my experience, this information is very difficult to obtain in advance.

Billing Code (also CPT or medical code): a series of numeric digits assigned to a medical service or procedure. The medical billing and coding process involves reviewing information from patient charts, coding this information, and then submitting these codes to the insurance provider. The codes are a standardized method used in order to communicate what service was performed. An individual is not always able to obtain the contracted rate for procedures in advance, but this code will be necessary in order to do so.

Cash Pay: when an individual does not have health insurance and instead is fully responsible for the cost of a medical service (see also: Cash Price).

Cash Price: a predetermined amount that a medical provider will charge an individual if they do not have heath insurance. Typically, the cash price is highly discounted from the amount a medical provider would bill an insurance company.

Network: a group of medical providers (doctors, facilities, labs, etc.) that will work with your specific insurance provider. In-network providers are covered at a higher rate than out of network providers, resulting in lower patient costs. Often, an insurance company will not cover out of network services at all.

Appeal: the process of requesting the insurance provider review their decision (typically, the decision to deny benefits). Appeals can be limited by the amount of days that have passed since a decision, or by the amount of days the insurance provider will allow an appeal to be open once filed.

Grievance: different that an appeal. A complaint about something other than a coverage decision. For example, the length of time a medical provider takes to respond to an appeal records request. (Here’s a real life example: I appealed my insurances’ coverage denial for lab tests. As part of the appeal, my insurance company requested documentation from my doctor. My insurance company allows appeals to remain open for 60 days, but my doctor took over three months to provide the documentation. By then, the insurance company had closed the appeal. I filed a grievance due to the response time of my doctor and won. As a result of my grievance, the insurance company reopened my appeal.)

Other definitions you should know

HSA (also “Health Savings Account): a tax-free account that can be used to pay medical expenses.

Junk Plans (also “Association Plans”): plans often offered to those that are self-employed or unemployed. They are cheaper than traditional health insurance plans, but frequently do not meet the minimum requirements of the ACA. This means, among other things, that these plans may not cover services required by the ACA, that they may exclude services based upon pre-existing conditions, or they may have lifetime limits on coverage. It is IMPERATIVE to read and understand every word of the fine print when purchasing an Association Plan.

Affordable Care Act (also “ACA” and “Obamacare”): a law designed to offer health insurance to those without access to employer plans. The ACA also, among other things, has minimum essential benefit requirements, meaning that coverage is required in 10 essential areas. Some of these areas are: maternity and newborn care, prescription drugs, chronic disease management, and mental health and substance use disorder services. The ACA also mandates many things, some of the most important being: health insurance companies cannot deny coverage due to pre-existing conditions, may not impose a lifetime limits, and may not charge based on gender (ie: charge women more than men). ACA plans can be purchased on health care exchanges and tax credits are available based upon income level. Note that not all plans meet the requirements of the ACA (see also: Junk Plans).

Health Care Exchange: an online marketplace for health insurance plans.

How it works in real life

So, now that we’ve gotten through some definitions, how does this all actually come together and work? Let me provide an example from my real-life insurance situation. Again, this will vary slightly from your own plans, but the basic concepts remain the same:

Through my union, I have access to a group health insurance plan (this is uncommon for someone that has the freedom to freelance, but my union hires people in a non-traditional format).

• An example of how seeking care works: In March, I saw my endocrinologist. I had not yet met my $3000 deducible, so I knew that I would be responsible for all of the charges. I paid nothing out of pocket while at the office. My endocrinologist submitted their bill to my health insurance company. My insurance company sent me an EOB with the following information:
  
  • Service Date: March XX, 20XX
  • Service Provided: Office Visit
  • Provider Charges: $124.34
  • Max Allowed: $93.44
  • Discounted Amount: $30.90
  • Insurance Paid: $0
  • Patient Responsibility: $93.44
  • Shortly after that, I received a bill from my endocrinologist for $93.44.

This is how the billing will work for a typical endocrinologist office visit until I meet my $3000 deductible.

If I pay enough for medical services within a calendar year that I meet my $3000 deductible, then a typical endocrinologist office visit would be subject to coinsurance – mine is 50%. This means that I would owe 50% of the $93.44 and my insurance would pay the other 50%.

If I pay enough for medical services within a calendar year that I meet my annual Out of Pocket Max (mine is $7000), my insurance would then pay 100% of my remaining medical costs for the rest of the calendar year. If I were to visit the endocrinologist, insurance would cover all of the $93.44.

Fifteen (+) tips and tricks to reduce your healthcare costs

So now that we’ve walked through a real-life scenario, you can see that some people – despite having employer sponsored health plans and being well informed on how it all works – still have sizeable costs. The cost, along with the work required to minimize it, can be incredibly challenging for anyone that requires more frequent or more expensive care – especially those of us that are chronically ill.

If you – chronically ill or not – find yourself in a difficult financial situation while facing large medical bills, my own experience with the system has taught me a few tips and tricks that helped me deal with providers and reduce my medical bills. Here they are, in no particular order:

1. Try to always use In-Network providers. Check every single time – networks change. If you are going for more than an office visit, confirm the network status of every service provider you encounter. Lab, facility, etc. are often billed individually, and individually may or may not be in-network.
   
2. Contact your provider and insurance company up front. Try to obtain the cost in advance so that you can plan – be aware, this is sometimes impossible and can be INCREDIBLY frustrating.
   
3. Negotiate the billing code with the provider upfront. Sometimes your provider can be more selective with the services they provide, resulting in a different billing code and a cheaper visit.
   
4. Try to negotiate the price of services with providers upfront – I’ve never been successful at this, but it’s worth a shot! This trick applies mostly to those without insurance. If you have insurance, your cost is probably contracted with the insurance company.
   
5. Be aware of the cash price of services. This may help you negotiate after the fact. And yes, you can pretend like you don’t have insurance and request the cash price…but if you’re insured, technically that’s insurance fraud.
   
6. Ask for an itemized bill. Make sure your charges are accurate and argue charges that are inaccurate or extravagant. Fair Health Consumer has an EXCELLENT tool to research average medical procedure costs, it can be found here.
   
7. Know how to file an appeal, in case your insurance provider has made a mistake or if you want to push back on coverage denials. If filing an appeal, follow up consistently. Each and every time you contact your insurance provider, take thorough notes that include:
   • name of the representative
   • date
   • time
   • what was discussed
   • how long the next step will take (and then follow up again)
     
8. Find out if your provider or facility has a patient advocate or financial counselor. They will be able to help you determine if you qualify for financial assistance programs.
   
9. Find out if your provider or facility has financial assistance or charity care programs. Note: if they are a non-profit hospital – which most are – they are required to have programs of this nature. Here’s how you can find their program information:
   • Google the name of your facility/provider and “financial assistance.” For example, “Dignity Health Financial Assistance.” Locate and familiarize yourself with their assistance plans. Make sure to check and see if your income level qualifies you for debt forgiveness! There are organizations such as Dollar For that can help with this (check out their TikTok – it’s a wealth of information!).
     
10. Find out if you qualify for state, local, or charity assistance programs or grants. This will take a lot of googling, but medical grants and assistance programs ARE out there.
    
11. If you are able to pay your bill in full, request a discount for doing so – many providers offer this service. I’ve received up to 25% off for paying a provider in full.
    
12. Establish a payment plan. This is an interest free way to pay – do this before putting medical debt on credit cards.
    
13. If you establish a payment plan, pay the absolute minimum every month – literally $5 or $10 if the provider will allow it. After a year or so of paying, try calling to renegotiate your debt.
    
14. When all else fails, and if you are able to take the credit hit, let the bill get to the point of collections (or sometimes go all the way to collections – WARNING: this can show up on your credit report and affect your credit score) and then call the provider (NOT the collection agency) to negotiate. Recently, I’ve had a 100% success rate with this method and gotten an average of 40% off my most recent bills – all for waiting until the last possible minute to negotiate.
    
15. This last one is hard: don’t give up. The system is designed to send you in circles in order to wear you down. They want you to give up, stop fighting, and pay.

For those of us living with health conditions, being attentive to our medical bills and EOBs is an exhausting-but-necessary part of life. Do you have your own tips or tricks for managing healthcare costs or reducing what you owe? Or even tips and tricks to help manage the workload of confirming and/or reducing your costs? Make sure to leave them in the comments!

~ Until next time, The MLVL