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Can A Doctor Really Demand An Extra $75 Upfront?

Insurers prohibit doctors from charging more than a copayment or other amount specified in your plan.
Douglas W Allen
Insurers prohibit doctors from charging more than a copayment or other amount specified in your plan.

This week, I answer readers' questions about what doctors can ask for in advance and the nuances of switching insurance plans, both on and off the health exchanges.

Q. After signing up for a gold level plan on the health insurance marketplace, my physician, who is part of my plan, asked for $75 up front. My copayment is $25. His office also wants to keep a credit card on file. Is this legal?

A. Probably not. The contracts that physicians sign with insurers in order to be included in a plan's provider network include "hold harmless" provisions that prohibit doctors from charging members more than a copayment or other specified cost-sharing amount for services that are covered. In addition, many states have laws prohibiting providers from "balance billing" health plan members for amounts over what the insurer paid on a claim.

It doesn't matter where you buy your coverage; the same rules apply. "To the extent that there are state restrictions or contracts, they're the same in qualified health plans on the marketplaces and other plans," says Sabrina Corlette, project director at Georgetown University's Center on Health Insurance Reforms.

But given the sometimes chaotic enrollment process for the exchanges, it may be hard for providers to verify which patients are in network and when their insurance becomes effective. This could lead to confusion over how much patients owe.

Some physicians operate "boutique" practices that promise extra services or more personal attention for an additional fee. But it doesn't sound as if the $75 charge was related to any particular service or type of care that you received, and even if it were, you should have been told about it in advance.

Providers frequently ask to keep credit card information on file in case there are additional uncovered charges or you owe more than anticipated because you haven't met your deductible, for example. But "patients have to sign an authorization agreeing to that in advance, says Reid Blackwelder, president of the American Academy of Family Physicians, "or they can opt not to do so."

Q. Is there anything that would prohibit a young woman from dropping her existing coverage under a grandfathered health insurance plan and switching to a more comprehensive, health law-compliant plan as soon she discovers she has an expensive condition such as pregnancy or breast cancer? The grandfathered plan does not cover prenatal or maternity care and has high coinsurance and out-of-pocket cost limits.

A. In general, people can buy a marketplace plan only during the open enrollment period, which will continue until March 31 for 2014 coverage and begin again in the fall for coverage that starts in 2015.

If people have significant changes in life circumstances, however, they may qualify for a special enrollment opportunity that allows them to buy a new plan outside of the regular open enrollment period. These life changes include getting married, losing a job or having a child.

While the birth of a child creates a 60-day window to change plans, neither the pregnancy nor the birth itself would be covered under that new plan, says Dania Palanker, senior counsel at the National Women's Law Center.

However, if you get pregnant, it does change your eligibility for Medicaid, says Palanker. Medicaid covers prenatal care, labor and delivery, and 60 days of postpartum care. In most states, the income eligibility threshold for women who are pregnant is at least 185 percent of the federal poverty level --$29,100 for a two-person household in 2014. Medicaid pays for 40 percent of the births in the United States.

My employer dropped my 22-year-old son from my health insurance when he turned 18 and he is without insurance at this time. He's in college part time and works part time. I still pay for a family plan, and I believe he should be covered. Am I right?

A. You may be. Under the health law, most health plans that offer coverage for dependent children have to extend that coverage up to age 26, even if the child is financially independent or married. Until 2014, plans that had grandfathered status under the law could sidestep the requirement if the adult child had health coverage available through an employer. But when these plans renew their coverage this year, that exception no longer applies, says Sandy Ageloff, a health and group benefits leader at Towers Watson, a human resources consulting firm.

If your health plan is grandfathered, and if the new plan year doesn't start until later this year, and if your son has an offer of health insurance at his part-time job, it's possible that your employer can justify not offering him coverage until the new plan year begins. But that's a lot of ifs.

This column is produced as part of a partnership between NPR and Kaiser Health News.

Copyright 2021 Kaiser Health News. To see more, visit Kaiser Health News.

Michelle Andrews
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