My dad had a heart attack three days ago. When he got to the ER and gave his health insurance cards, they told him he doesn’t have insurance, but he obviously needed help.
After looking into it, I found out that someone convinced him that an indemnity plan is the same as real health insurance. He has a Manhattan Life - Insurance plan called Enhanced Classic Plus.
I’m struggling to understand all these documents. From what I gather, this is like umbrella insurance or something similar. He spent two days in the hospital, drove himself there, received a stent, and I imagine the bill will include charges for ice in his water.
Can anyone share advice on what steps I should take next? How can I help him out? Thank you.
P.S: Big shout out to the nurses. I already wrote a thank you letter. He wouldn’t have made it without them.
What he has is not an insurance plan. It’s more like a discount plan that pays out around $8,250 after adjustments. If there’s any amount left to pay, that’s unfortunately on your dad. Don’t forget that ACA plans available on the marketplace will cover pre-existing conditions.
Bran said: @Mai
Yeah, I can imagine the total bill might hit around $108,250.
The discount plans can be hit or miss. Sometimes they work well, similar to what real insurance would negotiate, but the options can vary. It’s one of those things that you have to research before you really need it.
After clearing up the insurance stuff, check to see what charity care programs the hospital has to possibly lower the bill more. Most hospitals have these options, though they don’t always advertise them and the income limits are often higher than you’d think.
If the plans were misrepresented as replacements for ACA or full coverage, your state’s Insurance Commissioner might be able to assist. It can vary by state, but there’s a chance of getting restitution.
@West
I was going to mention that! I’ve dealt with many similar cases and managed to get millions in restitution for folks dealing with unexpected medical bills after buying what they thought was full health coverage.
This is why using an indemnity plan as the main coverage isn’t ideal. It doesn’t work for anyone as their primary medical insurance. Ask these two questions:
Is this really comprehensive major medical coverage?
If the answer is no, walk away.
What’s the maximum out of pocket amount if medical expenses hit $1 million?
If the agent can’t provide that, it’s time to move on.
@Sawyer
Sorry for the confusion. I should have been clearer.
I would say the cards he showed fall under more like ‘policy cards.’ He has a ManhattanLife dental/vision card, a pharmacy discount card, and an Affordable choice plan card. He mistook the last one for his health insurance. He mentioned one of the staff at the hospital signed him up to get help, but when they checked, his insurance wasn’t showing up.
Thanks for your comment, I’ll definitely explore financial assistance options, see about backdated Medicaid, and I’ll ask for itemized bills.
Consider trying to negotiate a cash payment with the providers for the best deal. Then you can try to file with the indemnity plan to recoup as much as possible.
To submit a claim for medical bills, request a billing statement from the hospital that includes diagnostic and procedure codes. Then, file the claim with the insurance company managing the plan.
Indemnity plans can effectively help with hospital costs. They work best as a supplement to major medical plans or for those who don’t want major medical coverage.
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Let’s assume that insurance won’t deny any claims. But just a heads up, that’s a possibility to prepare for. If the insurance ties this to any pre-existing conditions, they may not cover it.
Let’s assume everything goes smoothly regarding coverage. He will see two levels of benefits on his bills.
First, if the hospital is in-network, he’ll get an in-network discount. It’s tough to estimate this amount, depending on the hospital’s agreement with the insurance company. The discount could vary wildly.
After that’s deducted, the ‘fixed indemnity benefits’ will kick in, which should be detailed in the plan documents.
For example, if he has a bill of $10,000 for a procedure, and his in-network discount is 50% while the indemnity benefit for that procedure is $2000, the math works out like this:
10k - 50% = 5k
5k - 2k = 3k
He’d owe $3000 for that procedure.
It’s wise to hold off on paying anything until you receive his EOBs and check with the claims team to ensure all benefits were applied right.
Unfortunately, many indemnity plans do not have a maximum out-of-pocket limit. They also typically have a maximum annual benefit. That means, even if there are no issues with the claims, you might still have to cover a good chunk of the costs out of pocket.
@Arden
Thanks for putting all this down clearly!
I believe this is my dad’s first heart issue, so fingers crossed we’ll be okay on that front.
Sorry if this sounds silly, but with indemnity being a sort of side plan, is it on my dad to contact the company first? Since the hospital didn’t accept his coverage, or is it send in the EOB then file a claim?
@Lin
No matter if the person at the front desk recognized the insurance or not, they should have called the number on the back of the card. Do you know if they did?
Arden said: @Lin
No matter if the person at the front desk recognized the insurance or not, they should have called the number on the back of the card. Do you know if they did?
That’s definitely what they should do.
Too often, hospital billing staff hesitate to call and verify benefits because of how the digital systems work.
I can’t count how many times I’ve had supervisors apologize for incorrectly communicating coverage just because their front-line staff won’t verify benefits.