Insurance, Coverage, and Costs: March 16, 2023

Surprise-Billing Law Loophole: When ‘Out of Network’ Doesn’t Quite Mean Out of Network

Harris Meyer

Billing experts and lawmakers are playing catch-up as providers find ways to get around new surprise-billing laws, leaving patients like Danielle Laskey of Washington state with big bills for emergency care.

For Young People on Medicare, a Hysterectomy Sometimes Is More Affordable Than Birth Control

Gina Jiménez

While Medicare was designed as health insurance for those 65 and older, it also covers people with disabilities who are young enough to still get pregnant. Yet they often struggle to get their birth control covered and end up with large medical bills — or instead opt for hysterectomies or tubal ligations, which Medicare sometimes will cover.

Wrestling With a Giant: How to Dispute a Hospital Bill

Dan Weissmann

One listener tried to dispute a $1,300 “facility fee” with the treating hospital, his insurer, a bill-mediation service provided by his employer, and finally a debt collector. He didn’t win, but he learned valuable lessons about advocating for hospital discounts.

Eli Lilly Slashed Insulin Prices. This Starts a Race to the Bottom.

Bram Sable-Smith and Samantha Young

Eli Lilly's news that it plans to cut insulin costs for patients will help, not hinder, the recent efforts in California and by entrepreneurs such as Mark Cuban to offer lower-cost alternatives, drug pricing experts said.

Journalists Discuss Insulin Prices, Gun Violence, Distracted Driving, and More

KHN and California Healthline staff made the rounds on national and local media this week to discuss their stories. Here’s a collection of their appearances.

Shaved Costs, High Risk, Maximum Profits: Regulators Worry About Florida’s Butt Lift Boom

Daniel Chang

Social media marketing lures people to South Florida’s lucrative cosmetic surgery scene with the promise of cheap Brazilian butt lifts. But some researchers, patient advocates, and surgeon groups say that the risks of the procedure are generally not understood by prospective patients, and that an unsafe number of surgeries can be performed per day in office settings, maximizing profits.

Struggling to Survive, the First Rural Hospitals Line Up for New Federal Lifeline

Sarah Jane Tribble

Hospitals in New Mexico, Texas, and Oklahoma are among the first to apply for a new rural hospital payment model that shifts the focus of services away from overnight stays to outpatient and emergency care. Still, experts say the law needs to be amended to provide the right mix of care for rural communities.

Two Counties Square Off With California Over Mental Health Duties

Angela Hart

The state wants to stop paying Kaiser Permanente for treating severely mentally ill Medi-Cal patients in Sacramento and Solano counties and force the counties to take on the task. The counties’ leaders say they can’t afford it.

Biden Administration Urged to Take More Aggressive Steps to Relieve Medical Debt

Noam N. Levey

Consumer and patient advocates push for new federal rules to protect Americans from debt collectors and force hospitals to make financial assistance more accessible.

Covid Aid Papered Over Colorado Hospital’s Financial Shortcomings

Markian Hawryluk

Financial pitfalls at the nation’s highest-elevation hospital serve as a cautionary tale as rural hospitals emerge from the pandemic on shaky ground.

Biden Budget Touches All the Bases

Very little in the proposed budget released by the Biden administration is likely to become law, particularly with Republicans in charge of the U.S. House. Still, the document is an important statement of the president’s policy priorities, and it’s clear health programs are among those he feels are important. Meanwhile, five women who were denied abortions when their pregnancies threatened their lives are suing Texas. Shefali Luthra of The 19th, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times join KHN’s Julie Rovner to discuss these issues and more. Also this week, Rovner interviews Harris Meyer, who reported and wrote the two latest KHN-NPR “Bill of the Month” features. Both were about families facing unexpected bills following childbirth.

Why Does Insulin Cost So Much? Big Pharma Isn’t the Only Player Driving Prices

Arthur Allen

Big Pharma may be moving on from squeezing diabetes patients on insulin prices, but it’s the arbitrators that jack up prices for those who can least afford them.

California Explores Private Insurance for Immigrants Lacking Legal Status. But Is It Affordable?

Rachel Bluth

Nearly half a million Californians without legal residency make too much to qualify for Medicaid yet they can’t afford to buy coverage. A state lawmaker is proposing to open up the state’s health insurance exchange as a first step to providing them affordable insurance.

Biden Promises to Fight GOP on ‘Gutting’ Medicaid. Budget Talks Seem Like Another Story.

Michael McAuliff

As many lower-income Americans prepare to lose pandemic-era access to Medicaid, President Joe Biden vowed to stop Republicans from making deeper cuts to lower the national debt. Other changes may still be up for discussion.

Idaho Dropped Thousands From Medicaid in the Pandemic’s First Years

Rachana Pradhan

The removals, detailed in emails between state and federal health officials, hinged on disagreements over how states could disenroll people during the public health emergency. Consumer advocates fear the alleged violation signals the mess to come on April 1, when the pandemic-era Medicaid coverage mandate ends.

A Bitter Battle Over the ‘Orphan Drug’ Program Leaves Patients’ Pocketbooks at Risk

Sarah Jane Tribble

Patients who depend upon special drugs to treat rare diseases are caught in the crossfire as drugmakers and the FDA battle over regulations that reward companies for developing treatments for relatively small pools of patients.

California’s Massive Medicaid Program Works for Some, but Fails Many Others

Angela Hart and Bernard J. Wolfson

Medi-Cal serves more than one-third of the state’s population — offering a dizzying range of care to a diverse population. In the new “Faces of Medi-Cal” series, California Healthline will assess the program’s strengths and weaknesses through the lives and experiences of its enrollees.

Proposed Medicare Advantage Changes Cannot Accurately Be Called ‘Cuts,’ Experts Say

Madison Czopek, PolitiFact and Yacob Reyes, PolitiFact

CMS advanced two proposed changes that could affect Medicare Advantage plans. One would allow the government to recover past overpayments. As a result, it could reduce those insurers’ profits, leading them to increase enrollees' out-of-pocket costs or reduce benefits. But it's inaccurate to characterize the changes as "cuts."

Montana Seeks to Insulate Nursing Homes From Future Financial Crises

Keely Larson

Lawmakers are considering creating standards to set Medicaid reimbursement rates. But industry observers wonder whether the move would be too little, too late to bolster a beleaguered industry.

Reentry Programs to Help Former Prisoners Obtain Health Care Are Often Underused

Renuka Rayasam

More than 600,000 people are released from prisons every year, many with costly health conditions but no medications, medical records, a health care provider, or insurance.

After People on Medicaid Die, Some States Aggressively Seek Repayment From Their Estates

Tony Leys

States take drastically different approaches to recovering Medicaid money from deceased participants’ estates. Demands for repayment of Medicaid spending can drain the assets a person leaves behind, depending on where they lived.

Feds Move to Rein In Prior Authorization, a System That Harms and Frustrates Patients

Lauren Sausser

The federal government wants to change the way health insurers use prior authorization — the requirement that patients get permission before undergoing treatment. Designed to prevent doctors from deploying expensive, ineffectual procedures, prior authorization has become a confusing maze that denies or delays care, burdens physicians with paperwork, and perpetuates racial disparities. New rules may not be enough to solve the problems.

Medicaid Health Plans Try to Protect Members — And Profits — During Unwinding

Phil Galewitz

States are turning to the big health insurance companies to keep Medicaid enrollees insured once pandemic protections end in April. The insurers’ motive: profits.

Readers and Tweeters Urgently Plea for a Proper ‘Role’ Call in the ER

KHN gives readers a chance to comment on a recent batch of stories.

Planes de salud de Medicaid intentan proteger a sus miembros… y a sus ganancias

Phil Galewitz

Estos planes, muchos administrados por titanes de los seguros, incluidos UnitedHealthcare, Centene y Aetna, han visto aumentar sus ingresos en miles de millones a medida que su membresía aumentaba en millones.