(Oona Zenda/KFF Health News)
“My son was diagnosed with congenital CMV, a virus that can cause hearing loss. As part of this diagnosis, he will be required to have routine hearing tests every few months until he is 10 years old. I reached out to you because I wanted to know why my son’s hearing tests weren’t covered by our insurance and why we needed to pay for it.”
— Anna Deutscher, 29, from Minnesota, writing about her infant son, Beckham
Trying to figure out why her claim was denied took Anna Deutscher a lot of time and work.
Baby Beckham’s hearing screenings were preventive care, which is supposed to be covered by law. Every hearing test cost them about $350 out-of-pocket. Between those bills and Beckham’s other health costs, the family maxed out two credit cards.
“Everything just immediately goes right to trying to pay that debt off,” Deutscher said.
At times, she felt overwhelmed by her son’s medical needs, on top of working. Deutscher said she “didn’t know what else to do” when her insurance company kept saying no to her requests that it pay for the hearing tests.
No one wants to spend time fighting their health insurance company. Many people feel they don’t have the knowledge or stamina to do it. But if, like Deutscher, you’re denied for a preventive service, it may be worth it.
Here are a few tips — a slingshot and a few stones, so you can be David when facing a health care Goliath.
1. Check Your Policy
Read your plan documents to confirm whether the treatment or service is covered. Pay attention to any exclusions or limitations. Deutscher’s plan documents say hearing tests are not covered. But even when a sought-after benefit is excluded, that might not be the end of the line.
2. Is the Service Preventive?
Many types of preventive care are supposed to be covered without additional cost under the Affordable Care Act. If you receive a recommended preventive screening and have private insurance, including through the Affordable Care Act marketplace, there should be no copayment at the time of service, and you shouldn’t get a bill later. A small number of insurance plans are “grandfathered in,” which means you may not have the same rights and protections as the ACA provides. Check with your employer’s human resources benefits manager to find out for sure.
Here’s a list of preventive services health plans must cover and the list specific to children and young adults.
A physician recommended regular hearing screenings for the Deutschers’ baby, which the healthcare.gov list indicates should be considered preventive and covered by insurance. But JoAnn Volk, an insurance expert and a research professor at Georgetown University, said real life often doesn’t match what the law requires.
“It really does come down to everyone sort of being on their best behavior on the provider and plan side to truly interpret and follow what should be covered,” Volk said.
3. Peel Apart the Denial
If you’ve been denied coverage, you need to k …