How do I Get Help with Medical Bill After Insurance in California, if I Have Not Met my Deductible?

Health insurance is changing. It used to be that you (or your employer) pay a premium to the insurance company, and you pay a small copay when use healthcare services.  However, more and more people are covered by high deductible plans, where deductibles can cost thousands of dollars until the actual insurance kick in.  This has led to many unexpected expenses for patients.

 

Since you have insurance, you will have already received a discount that the insurance company negotiated for their members. This billed rate will be lower than what the healthcare provider will charge you if you are uninsured.  However, you are probably still stuck with a huge bill since you have not met your deductible.

 

Here are some strategies to try to lower your out-of-pocket expenses, even though you have insurance and you have not met your deductible.

Check The Bill for Information on Financial Assistance.​

You will most likely find a phone number or address to the financial aid office of the healthcare provider.  Look closely since this information is often buried within the fine print.  Call and ask them for eligibility criteria, and how to apply.  YOU MAY QUALIFY FOR FINANANCIAL ASSISTANCE EVEN THOUGH YOU HAVE INSURANCE!

Ask for Financial Assistance Policy

Many healthcare providers are required to have financial assistance policies.  California make this is requirement for getting a license to operate, some providers may have been ordered to establish a financial assistance policy due to lawsuits, other providers may be operated by a religious organization and had charitable foundations.  HOWEVER, YOU NEED TO ASK FOR THE FINANCIAL ASSISTANCE POLICY.  Based on our experience, many hospitals do not voluntarily tell the patients that financial aid is available.

Once you get the financial assistance policy, you can then try to qualify based on their stated eligibility requirement. Unfortunately, there is no common standard, as each provider have different policy.   Generally speaking, there are two criteria: Gross Income, and High Medical Expense.

 

Qualify on Gross Income

 

Most providers will consider giving discounted care to patients if their household income is below a certain level.  The eligibility criteria is calculated as percent of Federal Poverty Level (FPL).  The FPL in 2019 is:

 

The typical eligibility based on gross income is 350% of FPL, although some providers go up to 400% or even 500%.  This means gross income of $43,715 for a single household, $59,815 for a two people household, etc.

 

Qualify on High Medical Expense

 

​Even if you qualify based on income, you also need to qualify on the High Medical Expense.  Generally speaking, this means your out-of-pocket medical costs over the past 12 months exceeds 10% of your gross income.  Let’s say you made $40,000 in gross income, and your medical bill was $5,000.  Since $5,000 is higher than 10% of $40,000, you qualify for discounted care because you met both the gross income and high medical expense requirements.  However, if your medical expense was only $3,000, you do not qualify for discounted care because you met the gross income requirement but failed the high medical expense requirement.  Note that medical expense includes all expenses incurred over the past 12 months, not just the bill that you got. 

 

Dispute Accuracy of the Bill​

Assuming you do not qualify for Financial Assistance, you can then try to argue that the bill itself isn’t correct.  Call the healthcare provider for an itemized bill (see here for difference between bill summary and itemized bill).  Review the details in the itemized bill and compare that against the services you received.  You can try to argue that you have been overcharged.  However, this is a highly complex area in healthcare, and very hard to do for the average person. This is where our expert team can help you at no charge, by looking at billing codes and reasonable rates. 

 

Plead for Relief​

You can try to make a personal case and plead for financial relief.  The medical bill has to be crippling to your household budget for them to consider further discounts.   Typically, the calculation is the medical expense taking up the majority of your disposable income (defined as gross income minus essential living expenses).  Try to get the contact information of someone higher up in the billing office and write a letter directly to that person.  From our experience, lower level employees do not have the authority to approve these relief, nor do they necessarily care. 

 

Look for Help From Local Charities​

Look around for charities / churches / advocacy groups who may give grants based on need. You will be making a personal case to these organizations and hopefully you will get some help in paying these bills. The local government benefit office is often a good place to start.  

 

Ask for Payment Plan

When all else fails, go back to the healthcare billing office, and ask for a payment plan so you can split up the payments into more manageable amounts.  The payment plan is generally calculated as a percentage of your gross income minus essential expenses. For example, if you make $3000 a month and spend $2500 a month for essential expenses (such as rent, utilities, food, payment for a car to get to work, insurance, etc.), you may qualify for a payment plan that limits your monthly expense to $50 (10% of your disposable income of $500).  Even if you have to pay interest, it will probably be much better than the rates charged by credit cards or other lenders.

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California Medical Billing Advocates

1390 Market Street STE 200

San Francisco, CA 94102

415-632-3316

info@calmba.org

©2019 by California Medical Billing Advocates, Inc.

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