1 Sick & In Debt Handling Medical Debt 2007 CAA Forum September 7, 2007 Overview What to do when a client has a medical bill? Medi-Cal Defenses & Reimbursement Defenses for Enrollees of Managed Care Plans Defenses for Persons Eligible for County Care Maximum Hospital Charges for Uninsured and Underinsured Persons Debt Collection 1. Medi-Cal Providers Must Seek Medi-Cal Reimbursement If a provider knows a patient has Medi- Cal, the provider must bill Medi-Cal Patients should show BIC card or other proof of eligibility Provider may not demand payment from patient for covered services
2 2. Medi-Cal Providers May Not Balance Bill Balance billing = billing patients for the remainder of a charge left on a medical bill after insurer (Medi-Cal) pays Medi-Cal providers agree to accept Medi- Cal payment as Payment in Full Patient may still have to pay copayment or share of cost* 3. Medi-Cal Coverage Retroactive up to 3 Months Before Applying Medi-Cal must cover services received up to 3 months before the month of application if the beneficiary would have been eligible Hospitals should help with application for persons receiving treatment who might be eligible County workers must help clients secure the maximum benefits 4. Medi-Cal Must Reimburse Improper Out-of-Pocket Costs If a beneficiary pays for medical care out-ofpocket that should have been covered by Medi-Cal, Medi-Cal beneficiaries may seek reimbursement from the state (DHCS) if the provider refuses to reimburse (Conlan). Once someone has applied for Medi-Cal, they must now use Medi-Cal providers to get reimbursed by DHCS. Must file a claim within 1 year of services or 90 days after receipt of BIC card Call (916) for claim form
3 5. A Special Note About Share-of-Cost Medi-Cal Share-of-cost programs are a huge contributor to medical debt! Beneficiaries should ask if they fit in a nonshare-of-cost program Check the share-of-cost calculation Has the client s income changed? Is all of the income countable? Is the math correct? 1. Insured Patients: Knox Keene HMOs (including Healthy Families HMOs) and Blue Cross and Blue Shield PPOs are covered Enrollees must first go through their health plan s grievance system If the health plan does not resolve the billing dispute, then file a complaint with the Department of Managed Health Care: or HMO-2219 ( ) 2. Insured Patients: Common Billing Problems Balance Billing: Provider can t accept payment from health plan and then bill the patient the remainder. Emergency Room Visits: If the hospital is not part of the health plan, they must contact the health plan to see if the plan wants to transfer the patient or pay the hospital once the patient is stabilized. The patient should not pay.
4 3. Insured Patients: IMR Independent Medical Review: DMHC can review if the health plan denies emergency or other treatment as not being urgent or medically necessary. Follows same process as a complaint with DMHC (first file grievance with plan, then file with DMHC if not satisfied with outcome). 4. Insured Patients: Healthy Families Healthy Families patients have the same Knox Keene rights and procedures as other HMO patients. If the problem is that the child was determined ineligible for Healthy Families when the child was in fact eligible, the family will need to go first to the Healthy Families Program, then to the Managed Risk Medical Insurance Board. County Indigent Health Covers medically necessary care for indigent adults not eligible for Medi-Cal. Generally there is retroactive eligibility for services received within the month of application L.A. has a program that covers bills up to 6 months old. Patients must use county (or countycontracting providers).
5 Uninsured & Underinsured Caps on Hospital Charges (AB 774) People with incomes under 350% FPL who are uninsured or underinsured should not be charged more than government rate (Medicare) by a hospital. For most hospitals, this should be a 65-85% discount of the original charges. Patients should ask for an application from the hospital and negotiate a payment plan if they aren t given free care. Billing & Collection Limitations under AB 774 Hospitals must wait at least 150 days to report a bill to a credit reporting agency or start a lawsuit. Hospitals must wait even longer if an appeal is pending with Medi-Cal, Medicare, a health or disability insurance plan. Hospitals must also wait to collect against patients paying or negotiating payment plans in good faith under AB 774. Other tips for the uninsured See if covered by workers comp, victims of crime funds, personal injury, car insurance, spouse employment insurance Check medical bills carefully make sure all treatment was actually received Ask providers to seek uncompensated care funds Refer to community clinics rather than ERs
6 Prioritizing Medical Debt Medical bills should be paid after the necessities of life. Do not advise clients to pay a part of their bill just to slow down the collections process, unless you are a provider negotiating a payment plan. This may affect their legal rights. Fair Debt Collection Collection agents (or providers) are never allowed to threaten physical harm or jail, use obscene language, discuss someone s debt with third parties (employers, relatives, etc.), or call before 8:00 am or after 9:00 pm. If a client is being harassed by a collector, seek legal help. Resources Health Consumer Alliance Website: Contains advocate and client brochures in multiple languages Health Consumer Center of Los Angeles (800) Eligibility screening and legal assistance
7 Contacts Maternal Child Health Access (213) / Eligibility screening Other legal referrals Jen Flory Western Center on Law & Poverty (213) /
8 Medical Debt Fact Sheet #1 What Can I Do if I Get a Medical Bill? Medical Debt Fact Sheet Materials developed by: The Health Consumer ALLIANCE What are my rights if I have Medi-Cal? Health care providers cannot charge you for services that Medi-Cal covers when the provider knows that you have Medi-Cal and accepts you as a Medi-Cal patient. If you got a bill, ask these questions: Look at the bill. Did you or your child get those services? Call the provider if you think you did not get the services in the bill, or if the bill is unclear. You have the right to ask for a detailed bill that lists all the services you got and the dates you got them. How To Make Them Say Yes Did you show your Medi-Cal card (BIC) to the provider? If you did not show your Medi-Cal card to the provider or the provider s staff, you should take your card to the provider. Ask the provider to bill Medi-Cal for the services. Do this right away! In the future, always show your Medi-Cal card when you get care. Did you have Medi-Cal coverage for the month when you got the services? Check with your Medi-Cal eligibility worker if you are not sure that you had coverage that month. Did you have a share of cost for the month when you got the services? A share of cost is an amount you must pay or agree to pay for health services each month before Medi-Cal will pay for your health care for that month. Most people on Medi-Cal do not have a share of cost. If you have a share of cost, Medi-Cal will not pay for bills that month until you have received services that add up to your share of cost for that month. If you cannot afford to pay your share of cost now, you must ask your provider to bill you for the share of cost and you must agree to pay it in the future. Please turn the page for more information English 7/07
9 Are you in a Medi-Cal managed care plan? If you are in a managed care plan, you have to get your medical care from providers in your plan, unless it is an emergency. You may have to pay the bill yourself if you went to a provider who is not in your managed care plan without getting approval from the plan before going. The only exception is if you had a medical emergency. Call your plan's Member Services phone number if you are billed - either by a provider in your plan or for an emergency. See if they will agree to pay the bill. You can also ask your plan's Member Services how to file a grievance if the plan does not pay the bill. The phone number for Member Services is on your insurance card. If the plan will not resolve the bill or if you still get bills, you can ask for a State Fair Hearing by calling If you got a denial letter from your plan, you must ask for a State Fair Hearing within 90 days from the date of the letter, unless you and your provider want to keep your treatment going. Then, you must ask for a State Fair Hearing within 10 days. Call us for advice about a hearing. If your health plan does not resolve your grievance within 30 days, you can file a complaint with the Department of Managed Health Care. Call or TDD You can ask for an Independent Medical Review (IMR) if the plan refuses to pay the bill because it does not think the services you got were "medically necessary" or if you have paid the bill and the service was an emergency or urgent. An IMR is a review by another doctor who is not part of your health plan. If the IMR doctor finds that the medical services you got were medically necessary then the plan will have to pay the medical bill. In most cases, you must file a grievance against your health plan and wait 30 days before asking for an IMR. You cannot get an IMR if you have already have had a State Fair Hearing. To ask for an IMR, call Are you in regular Medi-Cal? Providers do not have the right to bill you if they accept you as a Medi-Cal patient and Medi-Cal should pay for the service. Send the health care provider a letter that tells them to bill Medi-Cal [you can fill out Sample Letter 1 in this packet]. If you still get bills, call us for advice. Call us if you need help. Health Consumer Center of Los Angeles Van Nuys Blvd., Pacoima, CA
10 Sample Letter (Your name) (Your address) (Your City, State, and Zip Code) (Your phone number) (Today s date) TO: (Name and address of the provider or collection agency from your bill) RE: (Name and address of the person who got the services) (The account number from the bill) (Date the patient got the services) Dear Sir or Madam: This letter is to inform you that I (or my child) had Medi-Cal coverage on the day these service were received. The Medi-Cal identification number is (The Medi-Cal ID Number from the card of the person who got the services), issued on (The date of the card). The date of birth is (Date of birth of the person who got the services). A copy of the Medi-Cal card is enclosed. Although I (or my child) have Medi-Cal and I provided the Medi-Cal card at the appointment, I have been billed for services I got from you. (See copies of bill(s), attached.) California Welfare and Institutions Code Section and 22 California Code of Regulations Section prohibit providers from attempting to obtain payment from a Medi-Cal beneficiary once the person provides proof of Medi-Cal eligibility. This letter serves to formally notify you that I have Medi-Cal. Therefore, I respectfully request that you stop all attempts to obtain payment from me and instead submit a claim for payment for the services I received to my Medi-Cal managed care plan or to the State EDS program. You may submit a claim to EDS to: EDS Medi-Cal Claims P.O. Box Sacramento, CA If you have questions about where to submit the claim, please call the Provider Support Center at Please send me written confirmation that the above account has been closed. Your prompt attention to this matter is greatly appreciated. Sincerely, (Sign your name here) (Print your name here) Medi-Cal Bill Sample Letter 7/06
11 Medical Debt Fact Sheet #2 Healthy Families and Your Child s Medical Bills Medical Debt Fact Sheet Materials developed by: If your child gets Healthy Families and you follow health plan rules, you will not get any bills. Sometimes, though, you may get a bill by accident or because you did not follow health plan rules. If you get a bill, ask yourself these questions to figure out why you got the bill: Did my child get the services that are listed on the bill? If you think the bill is wrong, call your child s doctor. Ask the doctor or staff to explain the bill. You have the right to ask for a detailed bill. The detailed bill should list all the services your child got and the dates of the services. Did I show my child s insurance card to the doctor? If you did not, take your child s insurance card to the doctor How right To away. Make Ask the Them doctor to Say bill Healthy Yes Families for the services your child got. In the future, always show your child s insurance card before she gets care. Did my child have Healthy Families coverage at the time of service? If you do not know, call Healthy Families at Calls to this number are free. You can also call the health plan s Member Services number for help. This number is on your child s insurance card. Did my child see a specialist without a referral from her main doctor? A specialist is a doctor who gives special care that your child s main doctor cannot give. For example, your child might see a specialist called an optometrist for eye care. A referral is a written permission from your child s main doctor to see a specialist. If your child saw a specialist without a referral, you may get a bill. You may also get a bill if your child gets specialty care without approval from the health plan. The Health Consumer ALLIANCE English 7/07
12 In the future, do the following to avoid bills from specialists: 1. Always get a referral from your child s main doctor. 2. Make sure the specialist is part of your child s health plan. Ask when you call to make an appointment for your child. Did my child need urgent or emergency care? Did I have to take my child to a non-covered doctor for that care? If you answered yes, your child s health plan should pay the bill. Call the health plan and ask them to pay the bill. The health plan number appears on your child s insurance card. Sometimes answering these questions will not explain why you got a bill. There are still things you can do: 1. Call your child s health plan for help. The Member Services number appears on your child s insurance card. If the health plan cannot or will not help you, ask about filing a grievance. A grievance allows you to file a complaint about your child s bill. If you file a grievance, your child s health plan must answer within 30 days. If this does not happen, call the Department of Managed Health Care (DMHC) at If you have trouble hearing, call the DMHC TDD line at Calls to these numbers are free. The DMHC is a government office that helps health care users with health plan problems. 2. The health plan may refuse to pay a bill if it thinks that the services were not necessary. First, you must file a grievance. If the health plan still refuses to pay the bill, you can get an Independent Medical Review (IMR). An IMR lets an independent doctor decide if your child s services were necessary. If the doctor says the services were necessary, the health plan has to pay your child s bill. To ask about an IMR, call Calls to this number are free. 3. If someone tells you that Healthy Families will not cover your child s services, you can ask for a program review. This is like a second opinion. For more information about a program review, call Healthy Families at Calls to this number are free. If you have questions about your child s bills, call us at the Health Consumer Center of Los Angeles. Our number is Calls to this number are free. We are here to help you! Health Consumer Center of Los Angeles Van Nuys Blvd., Pacoima, CA Production of this brochure funded by settlement funds from The MEGA Life and Health Insurance Company and by The California Endowment.
13 Medical Debt Fact Sheet #3 What Can I Do if I Get a Medical Bill? Medical Debt Fact Sheet Materials developed by: If you have no health insurance, ask these questions: Look at the bill. Did you get those services? Call the provider to find out what the bill is for if you think you did not get the services in the bill or if the bill is unclear. You have the right to ask for a detailed bill that lists all the services you got and the dates you got them. Have you applied for Medi-Cal? You may How be eligible To for Make Medi-Cal Them coverage even Say if you Yes are working. If you have children, they may be eligible for Medi-Cal. Call to get an application. Medi-Cal may pay for services that you got within the last three months. For example, if you went to the hospital in March, you could apply by the end of June to get the coverage. But do not wait to apply. Ask for retroactive coverage when you apply for Medi-Cal to have Medi-Cal pay those bills. Give your Medi-Cal worker a copy of the bills. After you apply for Medi-Cal, call the number on the bill and tell them your Medi-Cal is pending. Are you eligible for your county medical services program? County residents who have no other way to pay for health care may be able to get services through their county medical services program. If you were not told about your county program, ask the hospital or clinic that is sending you a bill why you were not screened for the county medical services program. You can also contact your county health department. Please turn the page for more information The Health Consumer ALLIANCE English 7/07
14 Did you recently lose insurance through an employer? You might be able to get COBRA coverage. COBRA lets you keep your health insurance after you leave a job or after you lose insurance you had through your spouse s job. Check with your last employer to see whether you can still choose COBRA coverage. You will have to pay the health insurance premiums if you can get COBRA coverage. COBRA premiums are high but may be less money than paying a large medical bill. Could you be eligible for charity care? If the bill is from a hospital, call the hospital and ask if you can apply for charity care. Some hospitals have charity care programs that help patients who cannot afford to pay their hospital bills. Do this right away! It will be too late to apply for charity care if the hospital sends your bill to a collection agency. Is the bill from a hospital? There are new limits on how much hospitals can charge and how they can collect money. Look at our issue brief, New Limitations on Hospital Billing & Collections, for more information. Were you hurt on the job or while you were doing something for your work? You should talk to your employer about making a Worker s Compensation claim. Worker s Compensation pays for medical care to treat injuries that happen while you are doing something for your employer. The bar association where you live may be able to give you a referral to a Worker s Compensation attorney. Is the medical bill from injuries caused by someone else? Be sure to talk to a lawyer who does personal injury cases. You may have a right to get money from the person who injured you. The bar association where you live may be able to give you a referral to a private attorney. Call us if you need help. Health Consumer Center of Los Angeles Van Nuys Blvd., Pacoima, CA
15 Medical Debt Fact Sheet #4 What Can I Do if I Get a Medical Bill? Medical Debt Fact Sheet Materials developed by: Tips for fighting a bill: If you get a bill, do not ignore it! If the provider stops sending bills, it may mean that your provider sent it to a collection agency. You may start getting collection notices. A delay does not mean that the bill went away. You may be able to fight the bill so do not ignore it! Speak up when you have bills that you think you do not owe. Keep good notes and keep copies of everything you write. 1. Write a letter to the provider who sent you the bill and tell them why you think it is wrong. You should also include any information that helps explain your case. Be as specific How as possible. To Make Them Say Yes Make sure the provider billed your health insurance. You should show that you had insurance on the day you got services. Send a copy of your insurance card. If your insurance needs your medical provider to fill out forms, be sure to send the forms to the provider. You should also include a copy of the bill you disagree with so that the provider knows what bill you are talking about. A letter from your doctor saying why the medical services were necessary will also help if you are asking your insurance to cover a certain procedure or treatment. Keep copies of your letter and any other documents you send so you have proof that you sent them. You may want to send your letter certified mail and ask for a return receipt. The return receipt is your proof that the provider got your letter. Write down the name and telephone number of people you talk to about your bill. The Health Consumer ALLIANCE Please turn the page for more information English 7/07
16 2. Ask for your medical records to see if you got the services you are being billed for. This is important if you are getting hospital bills for many services. 3. Call your health plan or insurance to find out why the bill was not paid, and see how the problem can be fixed. Your health insurance may have refused to pay the bill because of a mistake on the bill. Then call your provider s office and health plan to make sure the bill is paid and your account is cleared. 4. Call your provider or plan s Member Services phone number on your insurance card. Try to work it out with the plan. 5. If that does not work quickly, look in your insurance documents or health plan booklet (called Evidence of Coverage or Summary of Benefits) to find out how to file a grievance. You can call your plan s Member Services and ask how to file a grievance. Make your complaint or grievance in writing. If you are on Medi-Cal or Healthy Families, see Medical Debt Fact Sheets #1 and #2 for how to do an appeal. 6. There are new limits on how much hospitals can charge you. Take a look at our issue brief, New Limitations on Hospital Billing & Collections. Call us if you need help. Health Consumer Center of Los Angeles Van Nuys Blvd., Pacoima, CA
17 Medical Debt Fact Sheet #5 Avoiding Getting Medical Bills: Tips You Should Know Medical Debt Fact Sheet You can save yourself time and money by avoiding medical bills. Knowing a few simple tips can make your life a lot easier! General Tips If you have health insurance, tell your doctor, hospital, and other providers. Also, tell them if you have more than one kind of insurance. For example, some people have both Medicare and Medi-Cal. Always take your insurance card to doctor s appointments and to the pharmacy. Show your card to the staff. This will let them know to send the bills to your health plan. Ask them to make a copy of your insurance card. How To Make Them Say Yes Keep your information current. Make sure that the following people and organizations have your current address and contact information: Your doctor Your Medi-Cal worker, if you have one Healthy Families, if your children are in the program Your health plan If you do not have insurance, see if you can get government insurance. Some people who work can get Medi-Cal. Call to see if you qualify. Calls to this number are free. If you have children, they may qualify for insurance under Medi-Cal or Healthy Families. To get a Healthy Families application, call Calls to this number are free. Materials developed by: Always read health forms carefully before you sign them. Do not sign anything that you do not understand. If you do, you might agree to pay for services and treatments without knowing it. It is okay to ask your doctor questions about any forms she expects it. The Health Consumer ALLIANCE English 7/07
18 Tips if you are in a Managed Care Plan Read your Evidence of Coverage (EOC). Your EOC is a booklet that explains the rules of your health plan. Learn these rules and follow them. Before you make an appointment, make sure your insurance will cover the services you need. If you have questions about what is covered, call your health plan s Member Services number. You can find this number on your insurance card. Only go to the emergency room if it is a true emergency. Sometimes you may not know if you are in a true emergency. In this case, call your doctor s office right away. If the doctor cannot see you soon enough, call the advice nurse. The advice nurse can tell you if you should go to the emergency room. You can get the advice nurse number by calling your health plan s Member Services Department. Always get a referral from your main doctor before you see a specialist. A specialist is a doctor who has special training in one area of medicine. For example, a cardiologist is a specialist who takes care of the heart. Before your insurance will pay for a specialist, you have to get a referral from your main doctor. A referral is written permission from your main doctor that lets you see a specialist. If your health plan says you cannot see a specialist, you can file a grievance. Filing a grievance is like filing a complaint. Make sure you get health care from providers who are part of your health plan. Before you go to a new provider, make sure your health plan will pay for the visit or service. This is true even when your main doctor refers you to a specialist. Call the new provider and ask the staff if the provider is in your health plan. If you have questions about how to avoid medical bills, call us at the Health Consumer Center of Los Angeles. Our number is Calls to this number are free. We are here to help you! Health Consumer Center of Los Angeles Van Nuys Blvd., Pacoima, CA Production of this brochure funded by settlement funds from The MEGA Life and Health Insurance Company and by The California Endowment.