The department of Health and Human Services included in its terms and conditions for hospitals, clinics and doctors who receive federal emergency funding a clause which bans surprise billing. The clause states that, “for all care for a possible or actual case of COVID-19, the provider will not charge patients any more in out-of-pocket costs than they would have if the provider were in-network, or contracted with their insurance company.” The guidance further states, “HHS broadly views every patient as a possible case of COVID-19.”

Leaving the door open to allow everyone to be viewed as a potential coronavirus patient may not have been the intent of HHS. “Because the terms and conditions do not appear to be sufficiently clarified, there is a concern that there will be legal challenges around the balance-billing provision,” said health policy consultant, Rodney Whitlock.

Balance billing has been a health-care practice for years, allowing the industry broad control on how they bill patients. It is banned in many states, but there is no federal legislation on the matter. Jack Hoadley, a professor of health policy at Georgetown University, said the HHS terms for eligibility to receive CARES-ACT funding could address problems not explicitly sited in the relief legislation like patients billed for testing for COVID-19 when the results come back negative.

“The providers, the insurers, everybody else is going to need clarification, as well as, of course, all of us as potential patients,” Hoadley said. “That’s going to affect our willingness to seek testing or treatment.”

Balance Billing is a common problem when you go to out-of-network doctors not covered or partially covered by your health insurance. The consumer is charged for these costs in bills that could come weeks or months after the initial visit or procedure.

There are steps you can take, however, to mitigate these surprise medical bills.  First, be sure to check your Explanation of Benefits (EOB) which usually comes with the bill.  Check the dates to make sure the service you are being billed for is accurate and which services were actually performed by out-of-network providers.  Be prepared.  Get an itemized copy of your bill and know what the “usual” charge is for the procedure.  Sites like FAIR Health can help you determine what costs are common for medical procedures in your area.  Call the provider and ask to speak to someone in billing who can assist you with the bill.  You can also write to your insurer and request that they cover a portion or all of the balance billing.

Ultimately, one of the best ways to avoid balance billing is to make sure you go to network providers.  Call your insurer in advance, if possible, to make certain all your care is being handled by in-network doctors, from the surgeon to the anesthesiologist.  Make sure all lab work and tests needed in preparation for the surgery is covered as well.  

If you failed to meet the January 31 open enrollment deadline to enroll in a health insurance plan for 2020, you might still be able to get coverage this year. Covered California is allowing those who didn’t know about the new mandate to have coverage to sign up by April 30. Not knowing about the new law is considered a qualifying event. You will have to mark a box on the application saying you did not know that there would be a penalty assessed if you do not have health insurance coverage in 2020.

Enrollment increased for the first time in three years, according to statistics from the state-run marketplace, most likely due to the new tax to be implemented on those going without insurance. “I encourage everyone who does not have qualifying health insurance to take advantage of the special enrollment period,” State Controller Betty Yee said in a press release. “I like signing tax refund checks, not assessing penalties.”

While the federal government under the Trump Administration has been slashing its advertising budget for the federal marketplace, California has done just the opposite, spending nearly $121 million on advertising. The state has also increased the length of open enrollment, giving residents longer to sign up than in other states. These factors resulted in an increase in enrollment in California by 1.6% compared to a decline in the federal marketplace of 0.5%.

In a continuing effort to lower health-care expenses for Californians, Governor Newsom is proposing that the state manufacture generic drugs, leveraging the huge market of its residents to increase competition and lower pricing.  Along with asking the drug manufacturers to make rebates more available and establishing a health-care affordability office, Newsom maintains that the reforms would “put consumers back in the driver seat.”   

According to the Kaiser Family Foundation, six in ten Americans take a prescription medication and nearly 80% worry about the cost.  Also, three in ten don’t take their medications because they are too expensive.  Amid allegations of price-fixing by big pharma, Newsom signed a bill in 2019 to deter “pay-to-delay” agreements between drug companies and competing manufacturers of generic drugs that serve to delay release of the cheaper off-brands.  According to a study by the Federal Trade Commission, these deals to stifle competition cost consumers as much as $3.5 billion in higher drug costs every year.