The Insurance Coverage Gap and How to Address it

Have you ever found yourself paying medical expenses that you didn’t see coming? This generally happens when insurers and health plan providers don’t reimburse you for emergency services. This is a type of insurance coverage gap.

What is an insurance coverage gap?

When you opt for a health plan, you might think that you are fully covered. However, this is usually not the case. Instead, there are various situations where you are required to pay for after the healthcare service. It isn’t until later that insurance companies reimburse you. And, sometimes they don’t.

For instance, during an emergency, when you receive care from a hospital that is out-of-network, or you get assistance from a provider that is out-of-network even though the facility is in-network, an insurance gap can occur whereby you can be denied disbursements by the insurer.

How has the insurance coverage gap been addressed?

Here is how insurance coverage gaps are usually addressed.

1.    There was a time when insurers denied patients any coverage in case the patient was diagnosed with an ailment that was classified as “non-urgent” as per the American College of Emergency Physicians. However, this practice is long abandoned. The Prudent Layperson Standard that came into effect in the 90s required health care plans to deliver coverage based on symptoms rather than the ultimate diagnoses. To further avoid insurance coverage gaps, ACA extended this practice further to include smaller health plans and employer plans on top of Medicare and Medicaid.
2.    Even after such standards, the gap hasn’t been fully covered. Among various insurance providers, the problem persists. For instance, Anthem has an emergency room policy whereby it is possible for insurers to deny disbursements if they deem an ER visit to be nonurgent.  There are various states where this policy is being implemented. This includes Missouri, Georgia, Indiana, Kentucky, New Hampshire, and Ohio. However, it was met by backlash from both physicians and patients alike and has caused various lawsuits. In 6 months of 2017 alone, Anthem denied over 12000 claims on the grounds of “avoidable ER visits.” This isn’t the only issue that causes coverage gaps. Instead, the narrower the plans get, the more problematic it becomes.
3.    Various states have taken it upon themselves to address the issue. For instance, lawmakers of New Jersey went ahead and passed a bill regarding it. According to the bill, the billing practices regarding urgency out-of-network care have been altered. The bill restricts the amount that health care providers can charge on top of deductibles from the patients.

Conclusion

The best way to avoid an insurance coverage gap, or at least not be blindsided by it is by knowing your type of coverage. Databases that allowed users to know the charges of health care providers, how much is reimbursed under a given plan and how much is to be paid by patients, can help in creating awareness among patients.  

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