Transgender people across the country face discrimination and other barriers to care which can make it difficult to achieve their health care goals. These barriers are there for New Yorkers, too, and came up during a HCFANY-led focus group looking into how LGBTQ+ New Yorkers are affected by medical debt. Participants described high medical bills after coverage denials for gender-affirming care – despite plans covering these same procedures, like hormone therapy, for cis patients. The discussion also found that LGBTQ+ New Yorkers are still paying out-of-pocket for surprise bills, even as they should be protected under New York’s Surprise Bill Law.
LGBTQ+ New Yorkers should know that they can get support from the State and from advocates if they experience discrimination in the health care system. New York State requires coverage for all gender-affirming treatment and last year required NYS-regulated insurance carriers to develop evidence-based medical necessity criteria for gender-affirming care. All plans are required to submit their criteria to the State for approval and in June the State announced that carriers are complying with the requirements. This is important because it means medical necessity decisions are more standardized and if anything goes wrong, plan members have documentation of what the plan was supposed to do. Until the State required it, many plans had no written policies on gender-affirming care. When they did, their policies didn’t always match medical best practices and categorized necessary treatments as cosmetic.
In its “Health Coverage Information for Transgender New Yorkers” guide, the state describes the process for appealing denials or filing complaints with the state when your rights have been violated. You can also get help from programs like the Community Health Advocates. They can help you no matter what type of insurance you have. Fighting to get health care you need can be exhausting and painful – if you want help, you don’t have to take on the entire burden by yourself.
CHA advocates can also help with the surprise bills that so many focus group participants described. These billing problems included bills that are clearly covered under New York’s Surprise Bill law and receiving multiple bills of varying amounts for one service. One participant received a medical bill that was so unclear she could not find contact information to pay it, even after multiple calls to the hospital where she received care. Another described conversations with their providers’ billing office as feeling “like a tennis ball being bounced around different courts.”
New York should continue to monitor insurance policies on gender-affirming care and ensure that plans who violate coverage requirements are held accountable. It should also make sure that consumer assistance programs like CHA are fully funded so that patients have support dealing with unclear and unfair medical bills.
Medicare is a life-saver for older Americans, but it does have out-of-pocket costs that can expose some patients to medical debt. A new issue brief created for HCFANY by the Medicare Rights Center explains some of the causes of medical debt for people enrolled in Medicare and describes some steps patients can take to avoid it.
Some of the causes of medical debt for people covered through Medicare are the same as for people with other types of insurance. More and more New Yorkers say they cannot afford to pay for care because of deductibles and out-of-pocket costs. This can be especially difficult for patients who are cannot afford supplemental coverage but are not low-income enough for Medicaid.
Like other patients, people with Medicare deal with medical billing errors and service denials. Patients who have had their care plan denied by insurers are then in a position where they have to ask their doctor for a different care plan; attempt to appeal, which can be overwhelming without help; or pay on their own. Finally, Medicare patients have to navigate covered versus non-covered services. Long-term care, dental care, and even ambulances can leave them on the hook for large medical bills.
Patients with Medicare coverage should review their Medicare Summary Notice to know what bills may be coming and whether any services they’ve received in the past three months were not covered. They can get help with billing questions, appealing service denials, or finding affordable care by calling the Medicare Rights Center at 800-333-4114.
New York State should also do more to protect patients from medical debt. One reason that medical errors are so common and that it is so hard for patients to know what services are covered by what providers is because the current health care system is so fragmented. A single-payer system, like the one that would be created by the New York Health Act, would eliminate the complexity that causes so much distress for patients in today’s system.
New York should also take steps to make medical billing more fair in the current system:
- Funding consumer assistance programs,
- Capping interest rates on medical debt judgments,
- Barring providers from placing liens on patients’ homes or garnishing their wages,
- Banning facility fees, and
- Making the state’s hospital financial assistance policy easier to apply for.
By Anna Szilagyi, Outreach & Program Development Coordinator, Medicare Rights Center
In September 2020, the Centers for Medicare and Medicaid Services (CMS) launched Care Compare, a redesign of their previous health care compare sites on Medicare.gov. Care Compare streamlines eight separate sites into one tool that allows Medicare beneficiaries to compare doctors and clinicians, hospitals, nursing homes, home health services, hospice care, inpatient rehabilitation facilities, long-term care hospitals, and dialysis facilities.
New York State announced a similar project for 2020. The goal of NYHealthcareCompare is to help New Yorkers compare the cost and quality of health care procedures at hospitals and access educational resources designed to help consumers know their rights, including financial assistance options and what to do about a surprise bill. Medicare enrollees may not have the same need to compare provider prices (except for non-covered services such as dental) as those with other types of insurance, but they do have the same problems with receiving confusing medical bills, being improperly billed, identifying in-network managed care providers, making informed decisions about their care, and finding providers with the highest safety ratings. CMS’s redesign of Medicare’s compare tool can offer direction to New York State in its design of a consumer health care compare site aimed at increasing health care transparency.
At medicare.gov/care-compare, Medicare beneficiaries and their families and caregivers can search by zip code, provider type, and optional keywords to get information on providers and compare up to three at a time. Once someone has started a search, Care Compare includes a list view and a map view (excluding for home health and hospice providers). The one-stop Care Compare tool is easier to navigate than using a different site for each type of provider, and the tool includes descriptions of each provider type to assist consumers with their searches. Care Compare’s design is a significant improvement from Medicare’s previous provider compare tools. However, not all provider information is relevant to consumers, and information that is relevant is lacking in certain areas.
When searching for doctors and clinicians, beyond basic contact and specialty information, consumers can see whether a provider is “participating,” which is important in estimating their Medicare cost-sharing. Participating providers accept Medicare’s approved amount for health care services as full payment and cannot charge beneficiaries more for Medicare-covered services. However, consumers enrolled in Medicare Advantage Plans would still need to confirm whether a provider is in network for their specific plan to ensure the most affordable care. Additionally, not all doctors and clinicians listed have performance information available, which makes it difficult to accurately compare providers.
Similarly, when comparing nursing homes, the tool shows how many fines or citations the facility has for fire safety and inspections. However, if the nursing home has not had an inspection, then the facility does not appear to have any quality issues. The importance of consistency and transparency is particularly important when comparing nursing homes.
Fortunately, Care Compare does include educational information for consumers in the compare view. Below the side-by-side comparison of providers, the tool includes next steps and key questions to ask before visiting a provider or receiving a health care service or procedure. For instance, when comparing hospitals, the tool links to the Medicare resources “Steps to choosing a hospital,” “How Medicare covers inpatient hospital care,” and “How Medicare covers outpatient hospital care” to help consumers make more informed health care decisions. This is also an opportunity to increase education and access to resources in New York State, such as financial assistance programs and consumer assistance programs.
While working to increase health care transparency for consumers, user-friendly tools with meaningful and relevant information are critical. In creating and updating a health care compare tool for New Yorkers, New York State should meaningfully engage consumers to identify what information and features are valuable to them. Consumer testing and focus groups could help inform NYHealthcareCompare and ensure the site is responsive to consumers’ needs.
While building out NYHealthcareCompare, New York State should consider including:
- Consistent and comprehensive quality measures to facilitate fair comparisons across health care providers. These measures should be clearly defined, so consumers understand how quality is assessed.
- Streamlined information that is relevant and comprehensible to consumers, such as insurance plans a provider accepts.
- Educational resources on questions consumers should ask before visiting a provider or receiving a health care service or procedure.
- Information to redirect people with Medicare to the Care Compare tool for comparing health care providers.
- Information on how to access financial assistance programs.
- Promotion of consumer assistance programs to help people navigate health care options and costs.
- A portal for consumer feedback and comments to inform updates to the site.
- Clear accessibility information, such as options to view content in different languages and larger type.
Insurers offering products in New York’s individual, small group, and Medicare Advantage markets submit applications to the Department of Financial Services (DFS) each year which describes how premiums will change and why. DFS (and HCFANY!) encourage consumers to respond to these requests by share their experiences with DFS. How affordable do you think your current plan is? What would happen if your premiums went up as much as your insurer asks for? You can read HCFANY’s guidance for how to comment here, and submit your comments to DFS here.
Insurers have requested an average increase of 11.2% for 2022 on the individual market, which is very high given that consumers are still navigating the economic and health-related repercussions of the COVID-19 pandemic; in addition, insurers will likely continue to benefit financially from depressed utilization and the increased use of telehealth as a result of the pandemic. In some cases insurers didn’t give enough information about why they think premiums should increase. This isn’t fair to the public.
In our comments, HCFANY discussed many reasons why DFS should consider reducing the rate requests, including both market-wide conditions and specific factors in each insurer’s application. Find your carrier in the list below to see what we had to say!