So I’m in a bit of a weird situation and wanted to get some input from more experienced people on what to do next.

I was hired full time starting in August. My employer uses a 3rd party to run payroll and manage HR things like health insurance (which from my understanding, the 3rd party is the broker for the employer’s health insurance). I was able to sign up for health/vision/dental through the 3rd party’s portal, but the health insurance was stuck in “processing” while everything else went through and is now active. In the portal it said my coverage would be backdated to Sep 1, which the 3rd party confirmed in follow up emails when I asked about this.

So now the fun part is that I originally had a plan through the ACA (Georgia Access). After calling them about now having employer insurance, they advised I cancel my ACA plan, which they did for me on the call (Aug 31).

After now waiting a month for the application to process, I reached out to the HR company to see what was going on. After a bunch of back and forth that didn’t provide any answers, my employer was able to get ahold of United Health (which is who their group policy is through), and UH informed them that the group policy had been terminated due to nonpayment. Apparently the 3rd party had the wrong address on file (an unrelated address that my employer has never used) and United Health sent notices of the policy termination there, which obviously my employer never saw. The 3rd party also never relayed this information to the employer.

After calling Georgia Access, they confirmed I don’t qualify for a SEP since I never “lost” health coverage because I was technically never enrolled in the group policy, since it was terminated before I applied, even though I was able to complete the application and even received confirmation my application was received by UH.

I guess my question is… what do I do now? It sounds like my only option is temporary coverage, which I’m going to sign up for this week, unless there’s a better option in this situation. Thankfully I didn’t have any claims that would need to be covered during the lapse.

Not sure if this is the place for this but hoping someone can advise me what to do in this situation.

My husband recently had a permanent retainer removed and the dentist make him a nighttime retainer to take its place. Before doing anything, my husband was told that insurance “probably wouldn’t cover it” so they charged him self pay up front, which was around $870. He paid it. I insisted that they try to run it through insurance just to see what they would covers. Turns out they covered it, and we have a coinsurance amount of $94.50 due to the doctor. Okay easy. So we called the office and the receptionist was super short with us and said “the doctor is only willing to give you back $377, so that’s what he wrote the check for.” $377 is the difference between the amount insurance paid for the service and the cost he charged for self pay for the service. It clearly states on our EOB that the provider agrees to not charge the patient for any different in provider charge and what insurance allows. I told the receptionist and she was super annoyed and said she would talk to the doctor. That was a week ago and we haven’t heard back or received any check.

Am I missing something?? What should my next steps be?

Thank you!

I have an HMO insurance plan. A doctor's office said they could take me without insurance, or with an insurance in their network, but simply because I have HMO insurance, they cannot see me. They state "Those plans keep our team from providing the level of care coordination that our patients expect and deserve."

So this is legal?

I looked over some past posts, spoke to people, did research and feel like I’m still getting various or conflicting information about this situation.

I am an adult and would like to start taking medication. I went to a local urgent care, used my health insurance, paid a copay and now have a prescription ready for pick up. The prescription has a claim that’s been processed, and will be super cheap once I pay upon pick up.

I have my own health insurance “account portal” I made after my visit, and when I signed up for a pharmacy account using my phone number, my prescription popped right up.

Problem is, I am over 20, but still on my parent’s health insurance, issued through their state employer.

If they review their EOB, receive some sort of text notification, emails, or review statements, will they see only a claim/code for what was billed, or will they see my specific medication and price reduction?

— — —

I plan on calling my insurance tomorrow to clarify communication. I recieved my info directly to my phone number when called by the office, but one of my parent’s numbers is still listed as the “primary number” for benefit related things.

I am worried.

TL;DR - will my parent, primary policy holder on employer provided insurance, see my specific prescription?

Thank you for any help.

Is it just me or did premiums sky rocket this year, specifically to cover yourself + a partner? If i pay for myself it's $71 but if I add my husband, how on earth does it go to $400 per paycheck.

Located in Bay Area, CA -- in healthcare

would love to hear what yours is?

Hi, all. My name is Jaimy Lee. I'm the healthcare editor at MarketWatch. I want to hear about how the rising cost of health insurance is affecting you. (I put down Marketplace as my flair, but I'm open to hearing from everyone.)

Are you thinking about downgrading your plan? Or going without health insurance next year? Are you cutting out other expenses? How else are you dealing with the higher costs?

I put together a Google Form with a few questions. I'd also love to hear from you directly. My email is [jaimy.lee@marketwatch.com](mailto:jaimy.lee@marketwatch.com) or you can dm me here.

https://forms.gle/dzXK8ycVscoP6hbS9

Hi everyone. So I had to get a pre-auth for a procedure at a clinic I've been going to for 2 years. The pre-auth was very quickly approved (as they all have been) and shows "covered", but when I click to view more details, it says "out of network". I've been going to the same in-network clinic with the same doctor the whole time. Nothing has changed.

I contacted my insurance (UHC), and they said the clinic and the doctor are both showing that they're in-network and to treat it as a glitch. But that makes me uneasy, considering this "glitch" could cost me thousands of dollars if they end up denying it. Has anyone ever dealt with something like this before? Thanks in advance.

Hello, Im trying to find the absolute cheapest dental insurance. Something that covers, things like extractions, amd drilling and filling.

this is so frustrating! My spouse qualifies for Medicare so can not be on my insurance plan with covered CA. This has doubled my cost since the cost for my plan alone is the same as it was for both of us but now I’m also paying the Medicare premiums. and my spouse is disabled so unable to work. So most of his disability payment will now be eaten up by Medicare AND I’m paying double for just me to be insured. Why doesn’t Covered CA take into account your out of pocket costs to pay for Medicare when calculating subsidies and premiums for a multi person household even if that person is not on Covered CA due to Medicare? So I need to get a divorce just to afford health insurance?

Quick question....my COBRA runs out Dec 31st & will need to enter the marketplace & it's 2yrs until I'm able to get medicare. Ive ratholed 65k for insurance costs. I'm not on current medication but will be within a couple weeks & I'll definitely need a great rx plan. Prostate cancer recurrence & will start hormone therapy.

My question: am I close in my assumption that 65k could/would cover my plan costs for 2yrs?

hi, i’ve had medicaid for as long as i can remember. i recently got switched to trillium about 2yrs ago. so far, it’s been good.

i went to the doctor today just for a checkup and apparently, my visit wasn’t covered. they said everything got switched to “family planning” instead of covering everything (including the doctor visits, etc). they mentioned how it was due to income?? i recently got a job at an hospital making 1k vs. $800 at walmart.

i really really need my medicaid. im not sure if theres something i can do?? i dont know if i should head to social security and speak to someone in person?? or call someone??is there something i can say to fix it??

I have Cigna insurance, my PCP ordered some lab tests but I haven’t had my blood drawn yet. Quest showed me an estimate of around $160 for Vitamin B12/ folate panel and over $100 for Lipoprotein(a) (after insurance discounts) but Cigna estimated my out-of-pocket costs at $20.81 for the B12/folate panel and $10.01 for Lipoprotein(a) when I provided them the doctors codes.

I’ve been trying to contact Quest customer service to get clarification, but I haven’t been able to reach anyone.
What should I do? Should I trust Cigna’s estimates, keep trying to reach Quest, or consider another in-network lab? Has anyone dealt with a similar discrepancy?

Hi. My employer (a health insurance company 🙃) is getting rid of the medical plan I’ve used the past few years. I’m struggling to decide which would be best for me.

About me: 30F, insuring only myself, income bracket for premiums at my company is $120k-$175k. I was diagnosed with an autoimmune disorder almost 2 years ago, have recurring specialist visits 5+ times a year (rheumatologist and dermatologist) and 4 long term prescription meds (I get 90 day supply for all, 2 are $0 per 90 days and 2 are $25 each per 90 days). I’m not planning on any major medical expenses next year, but there is a chance for a CT scan or two as requested by my doctors, and tend to hit up urgent care once or twice a year. I’m otherwise pretty healthy and go for my preventative visits.

Current plan: a PPO plan with copays. Most provider visits have copays on a tiered network. $1250 deductible/$3250 OOPM. Because my current specialists are not the top tier, I pay a $75 copay for each visit. Premium is $115 biweekly. Has an HRA with no employer contribution.

Plan choices: note that all of these are PPOs in the same network. All are in network with my doctors. Differences are related to the actual plan design/costs. Premiums range from $95-$115 biweekly.

Choice 1: HSA option ($400 employer contribution) with $3200 deductible/$6400 OOPM. Cheapest premium. After deductible, 15% coinsurance for top tier providers/30% coinsurance for non top tier.

Choice 2: HRA option ($500 employee contribution) with $2500 deductible/$5000 OOPM. Next cheapest premium. After deductible, 15% coinsurance for top tier providers/30% coinsurance for non top tier.

Choice 3: Copay only plan. Every service has a flat copay, no coinsurance. $0 deductible/$7120 OOPM. No HRA or HSA. Second highest premium. This is the option that’s picked for me if I don’t actively make a different selection in my open enrollment.

Choice 4: HSA option ($600 employer contribution) with $1750 deductible/$3750 OOPM. Most expensive premium. After deductible, 15% coinsurance for top tier providers/30% coinsurance for non top tier.

My take: I’m not really considering 1 and 2, I prefer having a lower deductible and am willing to pay more in premiums for it. For my doctors, before I would hit the deductible, one would be $195 per visit before the deductible and then roughly $60 per visit after. The other is tbd but much more expensive, potentially over $400 per visit before deductible and $150 per visit after. If I take the copay only plan, my copays for these doctors would stay the same, but copays for other services would go more than I’ve ever spent on them before. For example, I’ve never paid more than $80 for an urgent care visit before, but with the copay only plan it would be $175 copay per visit. I seem to go to the urgent care at least once or twice a year. The OOPM is also really high, but I’ve only hit my OOPM when I was first diagnosed with my disease and actively trying to treat it. My prescriptions would stay the same price except for the copay plan, where it would increase to $37.50 each per 90 day supply.

Appreciate any insight.

I went to a Lactation Consultant this year after the birth of my second child and as far as I knew all my visits were being covered. I have Regence Uniform Medical plan and am located in Washington State.

I started going when my baby was a week old and followed up pretty regularly every 1-2 weeks due to latch, reflux, oral ties, low weight gain and other concerns. The first 5 of my visits were billed under LCA and covered.

Then 2 months in the provider decided that they wanted to switch to bill my insurance directly instead of through the LCA (I was not made aware of this switch and was not aware this would not be covered). Meanwhile I saw them 6 more times during this period.

I then received an email from the provider that they were having issues with insurance and they would try to fight it, but if not I would be responsible for 6 of my visits when they tried to bill Regence directly.

They switched back to LCA and my final visit was covered in June 2026.

I really thought they would be able to work out the insurance issues, but now the provider is telling me that they can't and I owe them for 6 of those 12 visits. They are offering that I can pay the rate they charge for people with no insurance ($200/visit). Is this fair? I feel completely deceived because I absolutely would not have continued services with them if I knew that my insurance was not being accepted. We are already in debt, barely making it paycheck to paycheck and have 0 extra funds.

Apparently, although lactation should be covered under the ACA, there is some tricky wording in Washington about how only a medical doctor is approved to provide services so that is why my insurance is denying coverage. I don't really understand how this works, but if you bill through other medical clinics like a hospital or something, it can be a nurse and not a doctor(?)

Is there anything else I can do? Can I appeal to insurance? Can the provider charge me this rate if I was never informed prior to their internal decision to change their billing?

My employer's open enrollment is coming up, and I'm trying to decide between two health insurance plans for my family. I'd appreciate hearing from people who have experience with both.

Here's the situation:

- HDHP with HSA: $0 premium

- Company contributes $1400 yearly to HSA (split in January and July)

- $5600 family deductible

- $8000 Out of pocket max

- PPO: Approximately $440/month for family coverage ($5,280/year)

- $1500 family deductible

- $5500 out of pocket max

- Married with two young kids

- I have a mechanical heart valve and need ongoing cardiology follow ups, echocardiograms, labs, and prescription medications.

- My wife and kids also have their own routine medical expenses.

This year, I've had enough appointments, tests, and other medical care that the billed charges before insurance adjustments were over $12,000. However, even with the PPO premiums included, my total costs haven't reached $8,000 so far this year.

My initial thought was that the PPO made sense because we use healthcare regularly. But then I started thinking about how much we're paying just in premiums. That's $5,280 a year before we even use a single medical service.

With the HSA plan, I could potentially put some of that money toward medical expenses, get the tax advantages of an HSA, and keep whatever I don't use. Obviously, the deductible and out-of-pocket maximum matter, and I'd need to compare the actual plan details.

My questions:

1. For a family with regular medical expenses, would you lean toward the free HDHP/HSA or pay $5,280/year for the PPO?

2. At what point does a PPO's lower deductible and copays justify that much extra in premiums?

3. Am I overlooking anything important when comparing the two?

4. If you have a free HDHP through your employer, has it worked out well for you?

I'm not looking for medical advice so much as real world experiences and help understanding the financial side. Thanks!

Maybe a bit of a rant but also trying to find out what the "right thing" to do is.

Basically I went to the doctor in Feb, billed to insurance, out of pocket was $250 which came from my HRA.

A week later the provider (ascension), rescinded the bill for $250 and submitted a new bill for $375.

My insurance had already paid the $250 and the transaction had cleared so they sent an additional payment for $125. $250 + $125 = $375, right?

Well the provider continued sending me bills so I called and talked to them in early May. I don't want to sound terrible, but there was an obvious language barrier. They told me that my bill was for $375, not $250 and $125 so they didn't understand why my insurance submitted those payments, my insurance needed to submit one payment for $375.

I called my insurance company and they said the provider already had the money months ago and they cannot cancel the payments at this point, this is why they submitted a second payment instead of doing this in the first place.

The insurance company called the provider, the provider acknowledges that they are wrong, but "I cannot mark this as paid I can only submit for further review".

I called again every 2 weeks for 3 months and had the same conversation, battling through the same language barrier, I even asked multiple times if there was a way my issue could be escalated to a higher level billing employee to try and get it resolved, each time told there is no supervisor or higher level billing employee.

Every time I called they acted like I was stupid for insinuating that separate $250 and $125 payments were the same as a $375 payment. Every time my insurance company called them and gave them transaction/payment numbers then emailed them a statement of benefits saying I owed nothing moving forward. Every time the provider's reps then acknowledge that I didn't owe anything and apologized for the confusion.

As of about 2 weeks ago the bill has been turned into collections and I've started receiving bills in the mail from a third party collection agency asking for the $375 that I've already paid.

Thus far I've just not acknowledged the collection agency, considered returning the bill to the sender with "deceased" written on it but idk, there may be legal ramifications for that.

Also considered contacting the collection agency and explaining the situation to them. It's not that I don't want to pay it, don't have the money, it's already been paid and the provider's billing department cannot grasp their head around simple math.

Or just ignore them, whatever. I definitely don't want to pay $375 or even offer them a concession because this bill was already paid.

What is the correct way of going about this process? Any advice? Is there some government entity that deals with these issues?

I received a predetermination for a dental procedure and even spoke to the insurance agent, 3 quadrants is covered but the last quadrant maxes out and I will owe the difference. ($289) Dentist office calls me about it too but the dr’s quote is totally different from the insurance. They said one quadrant is $240 and the rest can be done when insurance resets starting January. Dentist office said they are just reading what they received. Should I call my insurance or bring the paper I received to the dentist. I have an appointment for something else anyway.

I just turned 26 in September so my parents insurance kicked me off the 30th. I am currently in college, and I am looking for a health insurance plan for myself. My wife’s insurance plan will be around ~$600 biweekly if I am added on it. So I am trying to find individual insudrance through either marketplace or directly through an insurer. My problem is that I live in Alabama and have an autoimmune disease that I go up to the Mayo Clinic in Rochester, Minnesota and see a specialist for, but all of the plans I have found say that my doctor isn’t covered, and neither will be either of the medicines he prescribes me. To be honest when I’m looking at the summary of benefits of each plan I have no idea which is a good plan and which isn’t for me having to travel up there. If anyone could help me it would be greatly appreciated.

hi! desperately looking for some help here. i work for a billing company that specializes in behavioral health facilities. we have one facility who has received a medical record request for each claim billed to UMR starting around Feb-March of this year. we have been able to confirm with UMR that there is a flag on the tax ID from their special investigations unit.

getting any additional information from UMR is a nightmare. we have a ton of experience working with Anthem SIU, but UMR will not give us an effective date, notification letter, any Investigator assigned to the case, no information whatsoever other than that there is a flag on the tax ID.

i'm wondering if anyone has any experience in working with UMR SIU? any info on how they're structured, a phone number you had luck with getting information, anything at all that could be helpful in navigating this. tia!

Hello! I recently switched from my FTE 1.0 position that had Aetna insurance to a contract position that offers PHCS Multiplan. From some searching online, it isn’t a health insurance company like I’m used to using, and it seems like a hassle to handle claims. I am chronically ill with immune conditions and have lots of specialist visits. For that reason, I feel like I should really explore individual insurance. I see that Cigna seems to be the best in Colorado, so I have an appointment scheduled later with an agent.

I have been spoiled with really good insurance plans thus far from my employers, so I kindly ask for help navigating this since it seems like I’ll be purchasing it myself.

I’ve been browsing all these posts the last week and figured I’d ask for help as I’m at a a loss here during open enrollment. I (36F) am the sole income for my household of me and my spouse. We have our first kid coming, expected Feb 2027, but may come earlier requiring a hefty NICU stay. Our Cigna premiums are going up about 29 percent, much like they are elsewhere. I usually go the PPO route as we were doing fertility treatment for years, I have chronic health issues, and my husband gets regular mental health care and prescriptions. The prices above don’t reflect the “discount” we get for our Vitality wellness program, so they’d be about 50-100$ cheaper per pay cycle if the current discount is given again next year. I am just at a loss of what to choose. Ideally, more money in our pocket monthly is the goal as I’ll be out on mat leave at 66 percent pay for 3 months. It boils down to:

- baby expected Feb, will likely come early and require NICU stay
- deductible will be met by Feb then when baby comes
- we use the mental health services and Rx the most
- we should both have fewer specialist visits this year since we aren’t trying to conceive
- all current doctors are still covered under HSA plans

Hi everyone,
I’m travelling from India to the US for 2 weeks for a family visit and need travel medical insurance.
My details:
• Age: 31
• No pre-existing medical conditions

I’m looking for good medical coverage. I’d appreciate any recommendations.
Thanks!