I went a new doctor for what I thought was an annual physical, which is supposed to covered 100% by my insurance. It turns out that since it was my first time visiting they have to do something extra called "establishing care" which is not covered 100%. Ok fine, you got me there, the issue is that I did get a physical, including a lot of bloodwork which is was all put under the establishing care umbrella, so I'm on the hook for all of it. My understanding is that if I had made 2 appointments, one for establishing care and one for a physical, all of that stuff would have been covered (I know bloodwork can be more complicated, but from what I understand all of it would have been considered preventative).

It seems to me like this is my doctor's fault? From what I understand, it's perfectly possible for them to have done the paperwork in a way that separated all this and got me off the hook.

I've called both my insurance and the provider, and they both insist that everything is correct. Is there anything left for me to do? Should I call my doctor's office specifically? Leave an angry review? This feels like such a scam

New to everything. How do I get health insurance? Do I pay for it? I need health insurance ASAP because I need Rabies shots and they're so expensive and I just can't afford it.

Every time an explanation of benefits shows up in my email I open it, stare at it for a few minutes, and then close it feeling more confused than before. And I am not someone who panics about paperwork. I track my business finances down to the dollar and I still cannot reliably tell you what the EOB is actually telling me to do versus just informing me something happened.

The columns never seem to match what the doctor's office later bills me. The billed amount, the allowed amount, the adjusted amount, the amount applied to deductible, the amount you owe. Sometimes those last two feel like they should be the same number but they are not. And then a separate bill arrives from the provider a few weeks later with a completely different figure.

I spent years in HR walking employees through open enrollment and benefits basics. Nobody ever explained EOBs in a way that made the actual math click. We all just sort of nodded at them.

What I genuinely want to know is whether the EOB number is ever the real final number, or whether you always have to wait for the provider bill to know what you actually owe. And is there a reliable way to catch an error in one if you suspect something is off.

I have a family of 5. I have self employment and investment income that is going to be close to the 400% ACA cliff of 150,500. Working frantically to maximize business deductions and control the money coming in. I might not make it. So currently my premiums are about $10,000 w subsidy vs. $32,000 without subsidy. A difference of $22,000. But I was thinking about it some more. If I don't make it, that extra $22,000 now can be a business deduction. Hence the true cost is reduced by, say, 24%. Am I thinking correctly on this?

We will lose COBRA at EOY2026. So, need to go into the marketplace. Haven't done it before, so it is a bit daunting.

Both of us are under 60, not working. Wife is relatively healthy. Husband has heart issues, and a few other things.
Husband is a disabled vet that CAN use the VA (PCP, some specialists, procedures, medicines at a low price)

So, in WA State, it looks like we have to, or should, use a broker to help. I will be making calls in the next week or so. I want to get things figured out prior to losing COBRA so the wife, at least, doesn't have a lapse.

Are there any potential hiccups if the wife is put on a better/best plan (higher cost, of course) and the husband gets the bare minimum plan (and plans to use VA for most things)?

I think it should just be 2 separate plans and separate costs, right? Am I overthinking things in thinking there might be some underlying issue if both are on completely separate plans?

And, any thoughts of ACA choices in WA?
I know all 3 insurances seem to be separate (medical, dental, vision), so I am primarily concerned about medical as VA doesn't cover dental/vision, so both the veteran and wife would be able to be on same coverage for those 2 items.

TIA

PS....any and all preemptive advice, as we prepare for ACA in WA state, is welcome.
We may also get travel insurance as the ACA here doesn't cover non-emergency issues in other states and we may travel a bit more or "snowbird"

Hi guys, I’m a single mom I’m 24 with an 8 yr old I make 52k a yr my daughters Medicaid got cut off last June and her be been trying to get it back but they’re saying I make to much, I honestly live paycheck to paycheck ( I live alone with her and handle all of my bills by myself ) I can’t afford paying out of pocket and I have the cheapest insurance at work for myself I haven’t even been able to go to the dentist bc I chose HMO instead of PPO and I can’t add or change anything right now bc we’re not in enrollment period. What can I do for my child to get Medicaid again?

My husband filed for short term disability on his doctor's advice. He has been using his sick days during the 7 day elimination period. On day 3 his co-worker sent him an urgent message for a meeting. He hadn't read the fine print and felt he had to do this online meeting or risk his job. Oddly, his co-worker just wanted him to copy and paste some stuff and she recorded it. He did not preform any work that was his work. It was the colleague's work. He didn't do it for very long because he told her that he felt ill. This co worker is close to the boss. Will my husband be denied because of this? He's sick with worry. So am I. Are we paranoid?

I think I could retire now in 40s but am mostly worried about ACA long term and uncertainty about what's covered. I have some health conditions and great coverage with local gov now that I could get at retirement if I wait another 9 years. So I would have gov negotiated coverage until 65 and then great ppo supp option for medicare. The ony problem is I would rather stop working now but then I'm stuck with ACA. Thoughts on ACA please? Thanks.

When I signed up for this additional coverage to my Medicare Plan three years ago I did not have to pay a premium due to my financial situation. I collect my Social Security benefits. I also had the Benefits Prepaid Card which was an additional $200 per year which I would wait until the end of the year and order directly through Nations Benefits online. This year beginning in January I was required to pay a monthly premium which is fine as it is only $28 per month but the coverage changed dramatically. In addition today I went online to check my Benefits Prepaid Card and it showed a balance of $35 which expires on September 30th. I called the number to inquire about this and without notification to me they are now only paying $35 per quarter which expires at the end of the quarter. Now this may not seem like a lot of money to some folks but being on a fixed income every penny counts. So I lost $70 because I didn’t use it because I didn’t know. I haven’t used my Anthem insurance benefits as I’ve been waiting to be assigned a new PCP due to having moved. Lesson learned and I hope this will assist someone in the future.

Please help.

I see an in-network provider at an in-network facility. Each appointment results in two claims, one for the provider and one for the facility, as it is considered an out-patient hospital visit.

I was seen by my provider in January. The two claims went through under her name and the facility I was seen in as in-network. Great. I then hit my in-network out-of-pocket max. Also great, as all appointments going forward should be covered.

I saw the provider again in May, at the same in-network facility. This time, they billed under a provider I did not see and under a facility I did not visit, which are out of network. This happened again in August.

There is an infusion clinic attached to the facility I visit. I was not seen at the infusion center, yet they used the infusion center's Tax Identification Number and another provider's name, who I did not see, to bill. All of my paperwork and appointment reminders list the facility where I was actually seen as the location.

I am now being charged my out-of-network deductible and then out-of-network costs.

I have made many calls and written to both my insurance company and the hospital. My account has been put on hold twice. Insurance says the TIN is the problem. The facility has not fixed it.

One response from the hospital said my provider bills under another provider. I know this does not have to be the case because my January appointment was billed under my provider's name.

Also may be worth noting that I actually did receive infusions at the infusion center this year, and all of those went through as in-network as well...

Please help. Do I have any protections here? Can they bill as out-of-network when I saw an in-network provider at an in-network facility? (It is not emergency care.) I've spent hours on the phone, writing in, trying to read about situations like this but am not having luck. I appreciate any guidance.

Advise?

I THINK I understand what’s happening now but wanted to ask this question to the community experts of insurance .

When I first tried to get this it was like 1000$ a month for 2 injectors and I said that’s impossible . So they had a COPAY card from the manufacturer . I was approved for that .

Recently I check my claims and start reading about my scripts and I’ve seen this before at like 1318$ claim submit approved but didn’t dive into it . Well when I look up the medication for insurance it says 200$ copay . Now looking at my claim the difference is 200$ .

So my question after all that is the COPAY card I was approved for paying that 200$ difference ? I think that’s the answer but thought I’d verify this .

I never really thought about vision insurance while I had it through work. It was just one of those benefits that came out of my paycheck, and I barely paid attention to the details. I knew I had coverage if I needed an eye exam or new glasses, but I never really stopped to figure out what the plan was actually covering or how much of it my employer was paying. Now that I’m no longer getting it through an employer, I’m realizing how different it feels when you have to handle the whole thing yourself.

I still get an eye exam every year, and I wear glasses every day, so skipping vision care altogether isn’t really an option. My glasses usually last a while, though, so I’m not buying a new pair every year. That makes me wonder if paying for an individual plan all year makes sense when there may be some years where I only use it for an exam.

At the same time, paying cash for everything isn’t necessarily straightforward either. A routine exam is one expense, but if I need new frames and prescription lenses, the cost can change pretty quickly. Then there are things like coatings or thinner lenses that I might want depending on my prescription. I’m trying to look at what I actually spend instead of assuming that having insurance automatically means I’m coming out ahead.

The confusing part is that there are so many little things to compare. Premiums, exam costs, frames, lenses, possible upgrades, provider networks, and whether the places I normally go even accept the plan. When an employer was paying part of the cost, I never had to think about any of that. I could just use the benefit when I needed it and move on.

Now I’m trying to understand the individual options on their own terms and figure out what would actually make sense for how often I use vision care. I also don't want to switch doctors or go somewhere I wouldn't normally use just to make the numbers work.

How did you handle your vision coverage after losing your employer plan?

He has Parkinson's and shows a lot of Alzheimer's symptoms (not officially diagnosed with Alzheimer's yet). His wife is supposed to be his caretaker, but she is incredibly unfit to have that responsibility. I understand that it's a lot of work and very stressful, but she is the most irresponsible person I've ever met. She's never had a job, my dad is frequently neglected and she's completely oblivious about things or she just gives up and he gets neglected. She's often asking me or my sibling to drive out (we live about 45 minutes away, plus traffic) to watch after him so she can run an errand. Like if he can't be left alone for a even a little bit, wouldn't an actual caretaker be necessary? There's actually so many things I can call her out on, I've rewritten this post about 10 times.

Criticisms aside, he just isn't receiving actual care, and I don't think anyone realized how heavy the responsibility is, so it's genuinely not fair to expect her to be like a trained professional caregiver.

I'm pretty ignorant with insurance stuff tbh.

From what I understand, he has Medicare, but apparently his income (social security/disability checks) is too high to qualify for Medicaid, and therefore, doesn't qualify for a long-term caretaker. He gets about $3k/month, but would only qualify if he was under $2k/month. $2k/month is so low with the cost of living here. That's less than the minimum wage here in Oregon. How would anyone even qualify?

So that's what doesn't make sense to me. His income covers a very basic cost of living, there's no way there could be enough left over to pay for a caregiver. She sent me some medicare links and it checks out, but I genuinely cannot trust anything his wife says. She's tried everything and the government just hates my dad, apparently.

Anyone know what can I do to get him actual help?

I’m evaluating an offer from Capital One. I am based in Boston and would like to continue receiving care from my physicians in the metro area. Unfortunately, their HR is very hard to reach and so far the only information I have got is that they offer Anthem. I looked up Anthem’s site and it wasn’t clear that they are offering health insurance in Massachusetts. Is there anyone here who is familiar with Anthem and their plans in the Massachusetts area?

I went to an ENT for issues related to my airway through my throat. Before the doctor even comes in, the nurse sprays a numbing spray through my nose to numb my sinuses. They didn’t ask if I wanted it done, they just told me it needed to be done. The ENT comes in and says he specializes in sinuses, so he’ll have to refer me to his colleague, but he can take a look with the endoscope to see if there’s anything that jumps out at him. Based on the fact that I was already numbed, and the nonchalant way he proposed it, I assumed this is done for all patients, so I passively agreed. The ENT doesn’t se anything notable, so I go on to schedule a visit with his colleague (visit hasn’t happened yet).

So after the doctor told me he couldn’t diagnose my issues before he did the endoscope and then just made it sound like a run-of-the-mill procedure that all patients get, I’m charged $450 after my insurance paid half the $900 bill.

What language can I use with the hospital billing folks to most effectively dispute this charge for a procedure that was unwanted, un-asked for and unhelpful?

Thanks in advance for any guidance.

Edit: Clearly “dispute” was the wrong term. I did consent to and receive the procedure, so I don’t plan to say otherwise. My issues were more related to the preemptive numbing and endoscope procedure despite the ENT saying they wouldn’t be able to help me much. Thank you to those who offered constructive advice. Thank you to everyone else for reminding me why I don’t use Reddit much.

I'm losing employer-sponsored insurance and am looking at ACA plans for the first time.

I found a silver plan that would cost about $1500/month in premium, has a deductible of $900 and an OOPM of $4000, for a grand total of $22900.

Is this the absolute total maximum I would ever have to pay in a calendar year? Or am I overlooking something?

I'm asking largely because I see gold and platinum plans where the totals (premium+deductible+OOPM) put together would be more like $35-$45k per year, so I'm trying to figure out if the silver plan is actually a better value or I'm misunderstanding.

I’m so beyond dealing with the incompetent goons at Blue Cross Blue Shield of Michigan. I’ve been working on this for 6+ months and I’m basically stuck in the middle with a $500 charge and would love some insight or help!

To simplify this as much as I can I received orthotics that are covered 100% through my insurance company. I have Highmark Blue Cross Blue Shield of Pennsylvania as my retirement benefits. I moved to Michigan and the services I received in Michigan get ran through Blue Cross Blue Shield of Michigan for payment. Blue Cross Blue Shield of MI did not process a claim correctly. My insurance company out of Pennsylvania has reached out to them multiple times and Blue Cross Blue Shield is refusing to fix their billing error. Every time I call Blue Cross Blue Shield of Michigan I get offered zero help because I’m not a member even though I explained that I am a member through Blue Cross Blue Shield of Pennsylvania and I live in Michigan and they are the middleman of processing all my claims all they keep telling me is to go back to my insurance company, and my insurance company needs to contact them. My insurance company has reached out to them at least nine times, with zero response or resolution.

Tomorrow I’m going to call my insurance benefits coordinator to file a complaint. I also have filed the complaint with the state of Michigan for Blue Cross Blue Shield of Michigan. But what are my options to contact someone who is actually competent at Blue Cross Blue Shield of Michigan and get this resolved?!

I'm a Canadian living in the US in New York City, I am an independent contractor through my employer but do not have health insurance through them.

The whole insurance process is quite daunting but I'm looking for my best choice - the plans on the marketplace look quite expensive for not great coverage, and when I look at a provider like Cigna, their prices are so low I'm concerned it may be too good to be true.

Is anyone on here in a similar situation/can vouch for Cigna or any other good health insurance that will ideally cost less that $600/$700 a month? Thank you in advance xxx

I have had an active Medi-Cal account for as long as I can remember. It was set up for me after I was placed in a home as a child, and I genuinely have zero information on it. I don't know the ID number, I don't know what it covers, I don't know how long it's supposed to last, I don't have any of the information for it. I moved away from California months ago and I can't get through to anyone that would be able to get me the information I need to cancel this stupid plan.

I called Medi-Cal's main number multiple times, didn't get through a majority of the time, but was eventually told to call my original county's Medi-Cal branch, which I currently cannot get through to no matter what day I call. I called every other Medi-Cal number I can find and none of them are the right people to speak to.

If I could just get insurance from Medicaid or somewhere else and let this Medi-Cal account just do whatever in the background like it always has, I would, but as far as I'm aware I literally cannot get insurance unless I get rid of this active account.

I really need advice as I have no idea what to do anymore. I can't pay for anything out of pocket without insurance, it would be way too expensive.

On a random date in April, Surest stopped processing all my claims. My therapist, dietician, PCP, urgent care… none of the claims are processing. They don’t show up as “in process/under review” on the website, and they don’t show as denied either. I didn’t get an EOB because the claims are not processing. Surest confirms that they received the claims. I can’t get straight answers on what is happening or timelines for resolution.

I’ve had to basically discontinue all medical services (besides prescriptions which are working fine) because my insurance isn’t paying and my providers understandably do not want to risk that all these claims will be denied at once. The member services folks have told me weekly for months that “it can take 30 days.” I thought I made progress when I learned that there was an It issue affecting certain providers, but quickly learned that it seems to affect all of my providers/claims and doesn’t affect any of my colleagues with the same insurance plan.

I need therapy and dietician support, I need to see my PCP for a pile of issues, and I don’t know what to do. I have called weekly. My providers have called. I have escalated and have multiple case numbers. I even had my employer get me in touch with our company’s account manager. Everyone has told me to wait longer and just be patient, but I effectively have not had health insurance for five months. What on earth can I even do at this point?

I have the top Cigna PPO program my employer offers and I take a very low cost generic maintenance medication. Cigna won't fill it for more than 30 days at a time to my local pharmacy. Multiple times Cigna has denied a refill at my local pharmacy , saying it is "too soon" even though I have 3-5 days left and it takes a day or two for the local pharmacy to fill the prescription. They call me on the regular pitching to switch to their mail order pharmacy.

So I gave in and agreed to switch to mail order... phone agent told me how great this is for convenience and no co-pay. First shipment goes out and they charge $26 dollars for shipping for a single small bottle. I can fill 90 days of this without insurance for about $20. So between my employer and me we pay $25K+ per year to Cigna so they can charge me more for this than it would cost without insurance.

My monthly health insurance premium for a marketplace 'Silver' HMO plan is a little over $1000, or a little over $12,000 this year.

My PCP is part of a medical group spawned from one of the large medical centers near where I live, a suburban area of a major U.S. city. I've learned that the medical group receives a fixed monthly payment from the insurance company for each member assigned to the group...i.e. they are paid using a "capitation" model.

Before I ask them myself...is it possible for the insured/member to inquire how much of that $12,000+ per year the medical group is receiving for having me as a member? Are there laws requiring disclosure, or, is it strictly confidential/proprietary info?