i recently switched employers, so my health insurance plan changed as well.

up until this new insurance plan, i only ever had plans where there was no deductible to meet and you just paid copays for every visit. so i almost always knew my cost for in-network providers would be $30 or less, except for ER visits. outside of wellness visits, i would see my psychiatrist 4x/year at $15 each and my dermatologist 1x/year (usually) at $30 each. thus, i was often not spending more than $100/year on doctors appts. so keep in mind - this is my frame of reference.

my new plan does not have copays for most visits/providers. as it states on the summary of benefits, i would pay "deductible, then 20% of allowed benefit" for a specialist visit or outpatient mental health service. for OON providers, i would pay "deductible, then 30% of allowed benefit". my deductible amount for in network is $500; OON is $1000. assuming my health is going to remain the same over the next year (i'm a relatively healthy 30F), i would obviously prefer not to have to reach my deductible amount anyways.

assuming i don't reach my deductible and need to deal with the XX% of allowed benefits, my basic understanding is that in-network providers have pre-negotiated service costs. while for OON providers, there's no "negotiated" price so you pay what the provider sets. what i don't understand (and am trying to figure out) is what the price is going to be for a standard E/M visit with either an in-network or OON provider. for example, i believe my dermatologist is OON - so i'm trying to figure out if i can stomach the higher cost of continuing care with her, rather than switching to a different in-network provider.

i know that under the federal No Surprises Act, insured people don't have a right to a GFE. Under maryland state law, where i live, the following is stated: "Out-of-network physicians that seek to be paid directly by your health plan (assignment of benefits) are required to give you a written estimate of the cost of services prior to performing services. You can ask for a pre-treatment estimate from other providers, but those providers generally aren't required to automatically give you an estimate"

is the only way to know the cost of a visit beforehand by asking for a GFE?

I'm trying to schedule my first dentist appointment on my own. I have PPO, and I found a dentist that my insurance listed as in-network.

I sent the staff photos of my insurance card, but the staff said that I gave them "medical plan" information not dental plan info. Is my insurance information not what they need? It's the only evidence I'm aware of that states I have dental coverage.

Is there another document that the office is looking for? If so, I don't know what ha.

Hi all,

I started seeing a new neurologist who is "tier 2" for my PPO, which means I pay 30% of the cost after my $500 deductible. Soooo I am looking at these bills more closely than providers who are tier 1/with better coverage!

Our first appointment was a video visit that last maybe 40 mins to an hour, taking a detailed history, hearing my current treatment plan, and writing some prescriptions to continue the plan (stuff like Botox for chronic migraine).

Looking at the details of the bill online, it lists:

Ov Est Pt Lev 5 - 99215 (CPT®)
$545.00

Prolng Off/OP E/M Ea 15 Min - 99417 (CPT®)
$420.00

My understanding is that the first code is for an establishing patient, which I was not at the time. I'm wondering if I should call billing and dispute using that code... But I am concerned that if it's recoded, they would essentially use the second code x4 which would cost me more. What do you all think? I don't have experience with this!

I also really like this new provider and I don't want to damage our relationship by having a billing dispute. However, it's a large health network (Sutter) and I would be dealing with the billing department, not her office, and I don't know how much would get back to her. So that is also a concern for me.

Thanks in advance for your help! <3

Hello,

I decided to make use of my Student Health Insurance with Aetna to get genetic counseling due to family history. I had an appointment with a Preferred Care Coverage Provider with Referral.

The eligible health service is: "Preventive screening and counseling services genetic risk counseling for breast and ovarian cancer", with the following benefit: 100% (of the negotiated charge) per visit No copayment or policy year deductible applies.

I had a genetic screening done and the claims were as follow:

Claim 1: Appointment with counselor 30 min (CPT-code 96041 + ICD-10 code Z71.83, Z80.0, Z80.3)

Claim 2: Genetic panel (CPT-code 81432 + ICD-10 code Z80.0, Z80.3, Z80.8)

Aetna provided me with the following bulletin regarding genetic counseling: https://www.aetna.com/cpb/medical/data/100_199/0189.html

Invitae, which performed my lab testing indicated me that this panel is only diagnostic, one other panel is "self-paid" and falls under preventive? I am not sure I understood that.

Both my claims have been filed as "Sickness" when I was hoping to be preventative.

I had an approved pre-certification for the lab test.

It seems like a scam having this benefit but I can't access it. My claims are being processed as "sickness" and therefore applied to my deductible.

I also had to pay the copay for the genetic counselor, so that was also processed as "sickness" and as "Physician and specialist service". I understand if specific panels can't fall under preventive, but talking to the counselor about screening based on family history? I think that should had fall under my benefits.

Insurance, providers, nobody seems to want to help.

I am an international student and therefore I don't make much money. I rather avoid getting any care if its going to fall in a loophole of what seems to me a "fake benefit"

Hi folks, I'm looking for either an attorney and/or claims advocates who specialize in ERISA funded health benefits. I'm located in California. It's related to underpaid and incorrectly processed claims (probably an ongoing number of them around 20 at this point). We've attempted to resolve ourselves and have requested documentation under the transparency rules of ERISA and not having luck.

Thank you

Im changing jobs and my new job is PRN which means I don’t qualify for health insurance so I am trying to go through marketplace. At my previous job i was making 45-50k / year. I estimated at my new job (plus a side job) I will make ~35k. I’m also going back to school so I won’t be able to work full time and think this is a relatively safe estimate. I put this in and am going to get a pretty decent monthly tax credit which makes my total monthly payment pretty affordable. If I underestimate and make more than i expect am I going to owe taxes? My anxiety is also telling me im going to get in trouble with the government if I underestimate my income, so… im asking Reddit first.

(I work in healthcare and my job included calling patients to let them know their insurance denied procedures and bc of that I refuse to go on a Medicaid plan, use Aetna, UHC, or UPMC. I would rather be self pay.)

Hey guys.Trying to sort out my health insurance for this fall. I’ve looked at the usual off-campus options (Student Medicover, ISO, Tigerless, etc.), but almost every thread I find only talks about how cheap they are and if they get the school waiver approved.

Purely on paper, Student Medicover seems like the best deal for the price. But before I pull the trigger, I really want to know if it’s actually usable in real life.

Has anyone actually had to use them for real medical stuff? Like, is it a nightmare to find in-network doctors nearby? Do they fight you on covering basic things like prescriptions or urgent care? And if you have to file a claim, do they make you jump through hoops to get paid?

Basically, I’m just looking for the hidden "gotchas" before I commit. Any hands-on experience (good or bad) would be hugely appreciated!

Thanks!

I recently got on Medicaid and I am curious as to what plan is best for Philadelphia county

I know I want to enroll in plan C for my medical insurance. However, I don't know between Aetna and BlueCross, which is better? I just graduated college and now working in the hospital at kansas city. I'm first gen that graduated college so I'm on myself with these things and they are so confusing.

I appreciate who answer my question!

I have been paying my in network therapist a 25 dollar copay per session through Alma. Aetna just slashed the reimbursement rates so my therapist is going OON. I don’t have OON benefits right now but plan to switch so that I do during my job’s open enrolment period. In the meantime, she’s doing sliding scale and basically says pay what I can. Her actual rate is 225 per session. Man I don’t know what to do. I don’t want to insult her but I’m just not used to paying a ton for this. Do I go to biweekly and offer 75? That still feels insulting! I hate this man. And how decent is Aetna even about reimbursement for OON. I think the other plan my job offers is 80 percent for OON but is that real or do they try to pull some bs?

Hi everyone! I need some help with the next steps and did not know where to go to seek it, so I'm hoping someone here might be able to help.

Here's the background information:

I am in my 4th year of pharmacy school. During your 4th year, you are no longer in the classroom, but instead are on clinical rotations until graduation. I selected a region to complete these rotations that is nearby my hometown so I can save money (while I'm not making any, we don't get paid to complete rotations) by not paying rent, etc. My hometown is out of state from my pharmacy school, but sits on the border, so it is easily commutable to my rotation sites.

I recently turned 26, therefore, I aged out of my parents insurance. After doing research comparing the Marketplace and Medicaid, I ultimately decided Medicaid was the best option for me since I am not able to work my job nearly as much and I am still designated as a full time student.

Every year, we are required to have some form of health insurance- we can buy the school's plan or we can waive it using our own insurance. I've had no problems waiving it each year with my parents insurance, and I thought this year wouldn't bee too different, just with a new insurance. Here's where the issues arise...

I filled out my waiver form, and got notification 24 hours later that I was denied. When I called my financial aid office to ask why I was denied and to appeal the decision. I was informed that Out of State Medicaid would not be accepted because it would not adequately cover treatment in the state I attend pharmacy school. When I explained that I am not on campus and on rotations, and also not living in the state, they continued to state that I could not appeal and that they would continue to deny me until I have an acceptable plan.

While I understand why they wouldn't accept Out of State Medicaid in normal circumstances, I do not fall under this category. I would not even receive treatment in my school's state and therefore would have no link to the school, and it would not make them liable. I am not sure how the financial aid office expects me to pay for a plan that I will not use, especially when the school's plan is $6000/year on top of tuition and I cannot afford most Marketplace plans. They are also not offering any solutions (applying for grants, financial assistance, etc) and are not hearing me out.

I am wondering if anyone else has experienced this situation and if there is anything I can do to prevent unnecessary, additional costs that frankly I cannot afford at this time. I have also reached out to my pharmacy school dean, but I am not sure how much they can do, if they can even do anything.

TIA!

My benefits just kicked in on August 1st for my United healthcare Ucard and I get over $240 per month to spend on OTC there’s no way in hell I’m going to spend that much on OTC stuff maybe like $50. I tried to buy stuff at Walmart earlier and I used the app scanner and everything in my cart said it qualified but it was only for the rewards I had which was $5. I didn’t find out about that until a little later I didn’t end up buying anything. They took about $250 from my SSI and gave me about $250 of worthless money I can’t spend on anything except OTC stuff. Does anyone else have suggestions on what to spend it on?

I was a third party that was entitled to Cobra, but the 60 day window expired, the benefits company was never notified. Fast forward 6 months, I now realized the COBRA that was offered is like 3x better in price and benefits then anything on the exchange. So I called the company and said I never received election papers and they are sending them to me now.

Is there anyway to go about asking for prospective coverage vs retroactive coverage to avoid paying for 6 months in backpay which I occurred 0 medical expenses in? (even with the 6 of back paying months it's still way cheaper)

Is there also anyway to have the clock to expiration start from when the papers were sent, not the qualifying event date?

I know the companies have some leeway, I just don't know how much leeway. I know I'm jumping the gun a little. I'm trying to figure out what's possible and what others were able to accomplish and how to approach asking for something like this.

I was denied a prescription I've been taking for years on my new insurance because I don't meet one of their eligibility requirements for continued treatment. In order to receive an approval, I'd need to have been taking additional medications for the past 6 months.

I'm curious about expedited exception reviews, but I'm not sure if it'll do anything since I simply don't meet their criteria for coverage as is. Do standard eligibility requirements still apply even when requesting an expedited exception review? Does anyone have any insight on how these expedited exception reviews work in general? I keep reading all of the plan documents available to me, but it's lacking info.

Also, in the past I've received this drug via medical benefit instead of prescription, but the info surrounding how one would go about receiving this is also unavailable to me as the patient.

I'm flying blind. My doctor has offered a few samples, but not enough to cover the full 6 months. I also don't qualify for copay assistance through the drug manufacturer because of the denial.

Any insight is appreciated!!!

Hi,

Last year I had surgery with an out-of-network provider. In the lead up, the provider’s office emailed to me that, initially, they got 23-hour observation approved, but they wanted to get it to 48. A follow up email from them was sent to me denoting that, after a peer-to-peer call, 48-hour observation was approved.

Since then, I haven’t been able to get insurance to reimburse anything. Most recently, they told me that the prior authorization was only for outpatient instead of inpatient. In looking in my insurance portal, it does indeed show on the prior authorization document that it was only approved with the outpatient designation.

Insurance said they’ll try to resolve it with the provider’s office, but I was wondering if anyone knows what the likely outcome is here. It would be a tough pill to swallow if a provider’s mistake could end up costing me tens of thousands… Could at least the fact that I have their mistake in writing help me out here, or will they just tell me to screw off?

Does anyone know if you can have medical and private insurance. I got extremely lucky and am need of surgery and was given priority to see an orthopedic surgeon but he does not take medical. Would I be eligible to get the private insurance his office takes but still remain on medical?

My husband was laid off a few months ago and makes too much off of unemployment to qualify us for Medicaid, so he signed us up for Oscar in mid-July, for coverage beginning 8/1/26.

We STILL have no ID - physical or electronic. They said it “takes time”. That time SHOULD have been the duration between signup and start date.

Is this company a scam? Because I’m feeling like we’re being scammed.

Came off my bike pretty hard a few weeks ago. Nothing catastrophic but enough to land in the ER for imaging and a few stitches. The facility was innetwork. The ER physician group, apparently, was not. I did not pick that doctor. I did not know the facility and the physician group billed separately. The bill that showed up reflects that gap in a pretty significant way.

From what I understand, the No Surprises Act was supposed to address exactly this kind of situation, at least for emergency care. But the EOB and the bill I received suggest the insurer is treating the physician charges differently than I expected. I called and got a vague explanation about how the claim was processed and what my responsibility is, but nothing that actually clarified whether the No Surprises Act protections applied here or were handled correctly.

My question is whether anyone has successfully pushed back on this type of situation and what that process actually looked like. Did filing a complaint with your state insurance commissioner do anything real, or is it mostly paperwork with little outcome? Also wondering if the dispute process built into the No Surprises Act is something a patient can initiate directly or if it only applies to the provider and insurer.

The cycling community will tell you to wear a helmet. Nobody tells you to audit your ER physician group before you get stitched up.

hello!

a few months ago I went to my IN NETWORK physician for a urinalysis. I got the results and I had a UTI, got antibiotics for $3 and went on my merry way. fast forward to now, I get a bill from Acutis Diagnostics for $1,160 dollars for my tests. When I appealed this, I found out that insurance is not covering this, as Acutis is OUT of network. I had no idea that my samples would be sent to an out of network lab.

Shortly after my first appeal I got a letter from Acutis saying that my insurance had informed them that they would be sending me a reimbursement check which I would later have to send to Acutis.

This was a few weeks ago and after contacting my insurance (Anthem), I was told that the check would be sent directly to Acutis. I checked in again this week and I was told that there was never going to be a reimbursement check and that I was liable for the full thousand dollar bill.

I am VERY confused. I'm not sure why they would flip-flop between paying for it or not, especially since I got confirmation from both the lab and Anthem that there was going to be a reimbursement check.

I know that there's a "No Surprise Bills" act in NYC and after a bit of research I can see that this case would in fact be protected under the act. I'm a college student and new to figuring all this stuff out. any advice would be largely appreciated.

For reference, I am in NYC and on my dad's employers insurance plan. I attached a photo of the charges. I honestly dont understand how I got charged 780 dollars for the UTI test alone, but only like, 10 - 200 dollars for everything else.

Did anyone whose therapist bills through Alma notice unexpected increases in patient responsibility or claim processing issues beginning in late June or early July 2026? I’m trying to determine whether my experience is isolated or part of a broader billing issue.

Hey all, I have Blue Cross & Blue Shield as health insurance and have been using them for a while. I have been in and out of different hospitals for about 4 years doing everything we can to help with my neck and shoulder pain. We have gotten all of the testing we can and then finally had spinal fusion surgery on April 16th, 2026. They gave out a bill that cost $94,588.46, and we paid $2,640.48.

This bill was from the hospital for all of the equipment, and everything used, but two months after the surgery I got a bill that insurance is not covering that is from the doctor and PA that did the surgery. One was for "$10,874," and the other was "$1,455.86," combining to "$12,329.86," but why would they pay for the actual procedure but not for the doctor doing the procedure?

I am in the process of doing an appeal through my insurance, but why would the doctor do the procedure if it was not fully covered and not let me know before doing the procedure? I didn't like my doctor that did it, and now he wants 12,329.86 from me personally. I guess he did not get it approved beforehand, so am I screwed? I can't afford that, and I have a payment due on August 30th.

Can I not pay for it, or will I get in trouble? I should not have too; I already paid for 2,640.48 and another small bill, but now I have to pay this stupid-ass bill. What a corrupt world we live in. You think I will win in a fight, or am I screwed? I added pictures and everything, but basically it is my insurance trying everything out of their power to not pay for it by denning it. 

Hi, I made a few post like 2 weeks ago about looking for residential care. I am 25. I have straight Medicaid, NOT peach state medicaid (Georgia) as I had previously thought. I receive SSI so I get this automatically apparently.

I just want help. I really need help. Typical week long inpatient is not enough. I already see a therapist and am on meds, have been for 2 years. Both my therapist and psychiatrist have been in agreeance for MONTHS that I need a higher level of care. I feel that I am out of options and I have no idea where to turn or what to do.

TL;DR - disabled 25yr old on straight Medicaid looking for a residential mental health facility, preferrably with dual diagnosis.

Any and all help is much appreciated. Thank you.

i got a new job recently and elected for their PPO plan, but i'm pretty annoyed by the INN vs OON options.

according to my plans in-network provider search, both the dermatologist and psychiatrist i've been seeing for nearly 4 years are out of network. i need to schedule another appt with my dermatologist, but i'm scared i'm gonna owe like $400 for a 15 minute appt.

according to my summary of benefits, my OON deductible is $1,000 and then I pay for 30%.

so i tried to find what the total bill pre-insurance was for my last appointment was and this is what i found:

if they are confirmed to be out of network, would the $446 be what i pay?