US healthcare: terminology, appealing denial, and Medicaid eligibility

February 21, 2023 7:10 AM

A plain-language primer on US health insurance billing terminology like "copay," "deductible," and "premium," and on coordinating benefits between multiple insurance policies. If your insurer has denied coverage for a test or treatment, a possible way to shame them into reversing their decision. And a public service announcement for US Medicaid members: "For the last three years – since the start of the pandemic – the federal government had the states stop checking the financial eligibility of Medicaid enrollees. They're going to resume doing that in April. This means, if you (or your kids) are on Medicaid, at some point in April or as soon as your state gets around to you, you're going to be required to do a bunch of paperwork to keep your Medicaid."
posted by brainwane (13 comments total)

This is brief and clear -- I am going to show it to my kids!

This explainer, or something similar, should be part of the Personal Finance class that every kid in my town's high school has to take...or maybe in Civics, since access to health care distorts the entire society. :7(
posted by wenestvedt at 7:56 AM on February 21, 2023 [3 favorites]

Or, if you want the same info but you want to laugh and cry about it at the same time, Brian David Gilbert's Terrible Guide to the Terrible Terminology of U.S. Health Insurance.

Honestly, there's great info here, but maybe don't watch it. It's really depressing.
posted by The Bellman at 8:24 AM on February 21, 2023 [5 favorites]

Also: Never ask if the doctor takes or accepts your insurance. The correct question to ask is if they are in network for your insurance. They will all take your insurance, even if they are out-of-network, which would result in you getting a big surprise bill from the doctor.
posted by Thorzdad at 10:37 AM on February 21, 2023 [10 favorites]

You might also like to know about the No Surprises Act, which is in effect after Jan 1st, 2022. This bans balance billing in certain circumstances. For example, if your surgery is in-network except for the anesthetist, and they didn't give you an option prior to get an in-network anesthetist, you don't have to pay the out-of-network anesthetist charge.

In my experience, billers seem to mostly know about this particular law, with some who haven't caught up yet, similar to when the ACA mandated that some care be covered that wasn't previously covered. So if you get a bill, look at it very closely. Also, take screenshots of the directory where your doctor is listed so they can't claim they weren't in-network when you visited them.
posted by blnkfrnk at 11:19 AM on February 21, 2023 [6 favorites]

Are there real examples of the “talk to the hipaa compliance officer and request the names and credentials of the people who denied your claim” strategy working? It seems plausible, but I would not like to recommend this course of action to my coworkers based solely on a screenshot of a Tumblr post.
posted by Jon_Evil at 1:31 PM on February 21, 2023 [6 favorites]

Proper! Thank you, brainwane!
posted by rrrrrrrrrt at 2:50 PM on February 21, 2023

I really want to RTFA, I do, but it’s 3am and if the Brian David Gilbert video explaining all of this isn’t linked up there… it should be
posted by thedaniel at 6:24 PM on February 21, 2023 [1 favorite]

A very strong argument here for universal health care.
posted by nofundy at 4:33 AM on February 22, 2023 [1 favorite]

What a blessing this post is. Thank you!
posted by Jesse the K at 2:41 PM on February 22, 2023 [1 favorite]

An Arm and A Leg is a podcast focused on the cruel cost of U.S. health care. Experienced radio producer Dan Weisman personally crashed into this issue, looked around for help, and realized this was a beat that needed covering. He does original reporting and boosts the knowledge of dedicated fact-hunters and advocates from around the U.S. He tells how ordinary people have fought their insurance and won.
posted by Jesse the K at 4:08 PM on February 22, 2023 [2 favorites]

For the past 3 years Medicaid has still wanted documents and paper work from participants but sometimes didn't get them. Due to the State of Emergency Medicaid hasn't been closing cases due to failure to provide/people being over income. Now that part of the State of Emergency has been lifted and normal Medicaid guidelines will be in effect. Get those documents in order as soon as you can.
posted by Issithe at 9:34 PM on February 25, 2023

Which documents does Medicaid want? Does anyone have a good, understandable list?
posted by mightshould at 4:53 PM on March 6, 2023

mightshould, since Medicaid is run by the individual states, the specific documents Medicaid requests will vary by state. The American Council on Aging summarizes:

Proof of income may include copies of alimony checks, SSI or VA benefit award letters, tax forms, and pension statements. A letter of self-declaration of income may be acceptable when there is no other way to prove income. Requested documentation related to proof of resources might include statements from checking / savings accounts, certificates of deposit, money market accounts, stocks, bonds, and retirement accounts. The cash surrender value of life insurance policies may also be considered, and therefore, copies of life insurance policies might be requested. If equity value in one’s home or car has changed, documentation may also be required.

For example, in North Carolina, they say "Your Medicaid caseworker will try to complete your recertification using information from electronic resources - without contacting you. If your Medicaid caseworker needs more information from you to finish your recertification, they will mail you a letter." And the letter may include a Request for Information Form with some lines checked, meaning they want those particular items from you, such as "Bank Consent form/Release of Information".
posted by brainwane at 5:21 PM on March 6, 2023