“In-network” and “out-of-network” – for people with health insurance, those words mean one thing: money. If you don’t want to get charged extra, you get your treatment done in-network. It sounds straightforward, but sometimes it doesn’t work out that way, even when patients think they’re playing by the rules.

Jeffrey Craig Hopper, a probate attorney in Austin, Texas, knows all about following the rules. Still, accidents happen. Last June he was coaching a Little League practice session when an errant baseball smashed into his face.

His wife Jennifer Hopper remembers rushing to the field.

“His eye was swollen shut enough that we weren’t sure if he could see,” she said.

Even in that moment of panic, Jennifer made absolutely sure to drive him to a hospital in Austin that was part of their insurance network.

In the end, Jeffrey was okay. He broke some facial bones around his eye, but they healed and his vision was fine. The family settled the co-payments for the emergency room but was surprised when they later received a separate bill for more than $700 from the emergency department doctor.

“It felt kind of random,” Jennifer said. “How do I know who’s going to charge me, and who’s not going to? So that was the first question.”

Like many patients, the Hoppers assumed that doctors working at an in-network hospital would, of course, be “in network.”

As it turns out, that’s not necessarily true. Emergency room doctors, radiologists and anesthesiologists often don’t work for the hospital. They work for themselves, often in large practice groups, and it’s up to the doctors to sign their own deals with insurance companies.

Many of them don’t. In those situations, the doctors can bill the patient for whatever the insurance company wouldn’t cover  because the care took place outside of the approved network, a practice known as balance billing.

“I couldn’t let that go, it just felt wrong,” Jennifer said. “Because there was no way out. There was obviously no way we could have avoided the situation, given our emergency.”

The Center for Public Policy Priorities, a left-leaning Austin think tank, recently analyzed ER billing by the three biggest insurers in Texas – Humana, Blue Cross and United.

Its report found that in over half of Humana’s Texas hospitals, none of the ER doctors was actually in Humana’s network. For United, this occurred at just under half of the hospitals and for Blue Cross, at about a fifth.

The report’s author, Stacey Pogue, said balance billing is unfair to patients.

“No other consumer services are sold to us this way,” she said. “It would be like going into a restaurant, and ordering a meal and then getting a bill from the waiter, and from the restaurant separately, and the cook separately and the busboy separately. And some of them will negotiate with you on the price, and some of them will accept coupons, and the others don’t.”

The Texas insurance industry has said it would like ER doctors to join their networks, but it can’t force them to.

The ER doctors counter that insurance companies often don’t pay them enough when they join networks.

The economics of ERs are complex, explained Dr. Bruce Moskow, president of the Texas College of Emergency Physicians.

“In an emergency department, we see everyone and we’re not even legally allowed to ask if they’re going to pay their bill,” Moskow said. “Large numbers of people pay nothing.”

There is a mediation process in Texas for some of these out-of-network bills, but it’s only for certain types of insurance and certain situations.

Some states have tried to tackle the problem in different ways. In California, ER doctors can’t send a separate bill to HMO patients. In New York, a newly-passed law requires out-of-network doctors and insurers to hash out payment on their own, and leave patients out of it.

Texas insurers have indicated they’d be receptive to more changes, such as expanding the mediation process. It’s currently restricted to balance bills over $1,000 and certain types of PPOs.

“Just get the consumer out of it,” said Jamie Dudensing, the CEO of The Texas Association of Health Plans. “If you just leave it between the health plan and the physician, the consumer’s not dealing with this issue. Let us work this out through the private market.”

Jennifer Hopper said she spent weeks appealing the physician’s bill, going back and forth between the doctor and the insurance carrier. Eventually she filed a complaint with state regulators. After that, her insurer ended up paying part of the physician’s bill.

People are typically advised to do their “homework” ahead of time and know who’s in their network and who isn’t. But Pogue said that isn’t always possible, especially in an emergency.

“If you’re wheeled into the emergency room door, you can’t ask the emergency room physician who runs up to stabilize you ‘Are you in network or out-of-network?’” she said. “That physician needs to be concentrating at that point on giving you life-saving care, not rattling off the list of insurance companies that he or she contracts with.”

Hopper has tried to do her homework by figuring out where to go for a possible future ER visit. Online, she searched her health plan to find ER doctors who were in-network. But she found less than five at the hospitals her plan used in Austin. She doubts the odds of getting those doctors the next time she or a family member needs care.

“So the reality is, all the transparency in the world doesn’t change the fact that knowing everything, I could not be sure I would get a different outcome,” she said.

This story is part of a reporting partnership that includes Houston Public Media, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Andrea Borondy Kitt’s husband Dan lived for a year and a half after his October 2011 lung cancer diagnosis. She’s convinced, however, that he might have lived longer had Medicare paid for a low-dose CT scan of his lungs that could have caught his cancer in the early stages.

Nine months before his diagnosis, Andrea read about this test, which had demonstrated encouraging rates of detecting early stage lung-cancers in long-time smokers. She wanted Dan to be screened. But her husband, a 40-year smoker who had quit eleven years earlier, wouldn’t do it because Medicare didn’t cover it.

But in a Monday announcement, Medicare officials signaled this policy is about to change.

The draft decision by the Centers for Medicare & Medicaid Services would provide coverage for this test to an estimated 4 million Medicare beneficiaries. To qualify, the beneficiaries would have to be younger than 74 and, asymptomatic for lung cancer, but have pack-a-day habit for at least 30 years. Those who quit as long as 15 years ago would still be eligible for the screening.

Based on an analysis published in the journal American Health and Drug Benefits, the average cost of the low-dose CT lung cancer screening would be about $241 per person screened for Medicare.

The health law required as part of its essential health benefits provision that insurers cover this screening. But Medicare – not part of this mandate – has lagged behind.

In addition, the U.S. Preventive Services Task Force in 2013 recommended the low-dose CT scan for heavy smokers aged 55 to 80.

Lung cancer kills approximately 160,000 people each year and is the leading cause of cancer deaths in the United States, according to National Cancer Society statistics. It also has a poor prognosis, notes the USPSTF. About 90 percent of people who have the disease die of it. However, when diagnosed early, the prognosis improves and the cancer can often be treated surgically.

The treatments for the late stages include chemotherapy and radiation, both of which are often debilitating for patients, said Ella Kazerooni, the director of cardio thoracic radiology at the University of Michigan Health System. She said catching it early means doctors have a much better chance of finding a curable treatment.

“It’s both rewarding when you do catch it early, and you’re going for curable treatment — it’s a phenomenal place to be,” said Kazerooni, also the chair of the American College of Radiology and Lung Cancer Screening Committee. “For the great majority of people present, by the time they have symptoms it’s unfortunately spread too far.”

However, some critics have expressed concern about the risks of false positive results and over diagnosis. A “substantial proportion” of false-positive results occur, according to the USPSTF, and, though additional imaging can resolve most of these findings, some patients may require invasive procedures.

“The benefits of this have been overestimated, and the harms have been underestimated,” said Russ Harris, a professor of medicine at the University of North Carolina, Chapel Hill.  “If people were better informed, they would understand … the limitation of the screening’s benefit.”

Others cautioned that patients should not be misled into thinking that the screening is the counterweight to a serious public health problem. “Even with the screening, some people will still die … but this is secondary prevention,” said Alfred Munzer, former American Lung Association president and chair of Action on Smoking and Health. “It is a way of preventing people from dying from lung cancer, and it’s one that comes late in the game, but we have people who’ve smoked their whole lives and we have to care for those people.”

Meanwhile, Andrea Kitts understands that even if her husband had the test, it may not have identified his cancer at an early state. Still, she wishes he would have had the option of low-dose CT scan. “We can stop this. If lung cancer screening had been there, I might not be talking on the phone to you, but now the rest of my life is dedicated to lung cancer.”

The proposal, which would not be finalized until February, is now subject to a 30-day comment period. Such draft decisions are rarely reversed or significantly altered.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Mind the gap. When the 2015 open enrollment period begins on Nov. 15 for plans sold on the individual market, consumers should act promptly to avoid a gap in coverage.

Failing to do so could not only leave you exposed to unexpected medical bills—hello, appendicitis!—but you could also be hit with the penalty for not having health insurance that kicks in if you’re without coverage for three months or more during the year. The coverage requirement applies to most people in group and individual plans unless they qualify for a hardship or other type of exemption.

In 2015, the penalty will be the greater of $325 or 2 percent of household income.

The open enrollment period runs through Feb. 15, 2015. But if you bought a plan last year and need to renew your coverage, you must do so by Dec. 15 if you want it to start Jan. 1.

In general, you must buy a plan by the 15th of the month in order to have coverage that starts the first of the next month. So if you buy a plan on Dec. 16, for example, your coverage won’t start until Feb. 1.

If you don’t have insurance and you buy a plan by Feb. 15, your coverage will begin by March 1 and you’ll avoid owing the penalty since your coverage gap will be less than three months.

Last year, the marketplaces got off to a bumpy start and many people weren’t able to sign up for coverage before open enrollment ended on March 15. The federal government allowed anyone who got their application started before the deadline to avoid the penalty.

This year, President Barack Obama has vowed that the marketplace will function on time. “We’re really making sure the website works super well before the next open enrollment period.  We’re double- and triple-checking it,” he told reporters last week.

There is also another way that people can be affected by the coverage gap.  For people who are receiving premium tax credits but lose or drop their coverage, health plans are required to allow them a 90-day grace period to catch up with their premiums if they fall behind, as long as they’ve already paid at least one month’s premium that year. But they don’t have 90 days before the coverage gap countdown starts. If after three months someone still hasn’t paid what he owes, his coverage would be terminated retroactive to the beginning of the second month of the grace period.  In that case, the penalty clock for not having coverage would start ticking after the first month of nonpayment, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

People who aren’t receiving premium tax credits on the exchange would be subject to state laws regarding grace periods for nonpayment. Typically they’d have 30 days to pay up, Solomon says.

If you lose your job-based health insurance, you’ll have 60 days after your coverage ends to sign up for new coverage. This “special enrollment opportunity,” as it’s called, would count toward a gap in coverage.

Although people are limited to a single coverage gap of less than three months annually, some may be able to sidestep the issue.

“If you have coverage on any day during a month you’re considered covered for the month,” says Solomon.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Haven’t thought about the health care law for a while? Now’s the time.

Passed in 2010, the law requires most Americans to have health insurance or pay a fine.  While many Americans get health coverage through their employers, starting Nov. 15 consumers who currently have insurance through the federal or state online marketplaces, or exchanges, set up by the law can reenroll. In addition, people who still need health insurance can sign up. Subsidies are available to help many people afford coverage, and some states have expanded their Medicaid programs as part of the law.

Last year the federal website, healthcare.gov, as well as some state-run websites, experienced severe technical difficulties, frustrating consumers trying to sign up for the exchanges. Nonetheless, more than 7 million people bought insurance plans in the exchanges and about 8.7 million signed up for Medicaid and the Children’s Health Insurance Program, or CHIP. The Congressional Budget Office estimates that in 2015 exchange enrollment will grow to 13 million and the increase in Medicaid and CHIP enrollment will rise to 11 million, but the Department of Health and Human Services projects that exchange enrollment next year will be under 9.9 million.

This time around, federal and state officials have promised easier-to-use, streamlined applications. Federal officials say healthcare.gov is undergoing testing to make it better able to handle high demand.

Here’s what you need to know for the coming enrollment period.

I enrolled on the healthcare.gov last year. Do I have to do it again?

If you take no action and got your plan last year on the federal marketplace, officials have said you will be reenrolled in your current plan. But since some plans have changed and some new plans are coming on the market, they are encouraging people to go back on healthcare.gov to compare benefits and prices.

You should also update your income information to find out if you qualify for financial help to purchase coverage and to make sure you receive the correct amount. That’s because if your subsidy is too high, you’ll have to pay it back at tax time.

States running their own exchanges will make individual decisions about how they are handling automatic reenrollment.

Consumers will have just three months, until Feb. 15, to sign up for coverage, rather than the six months they had when the health law’s online marketplaces, or exchanges, began accepting applicants just over a year ago. If you want your coverage to renew or begin by Jan. 1, you’ll have to complete your application by Dec. 15.

Some plans that were available last year may not be offered for 2015 because the health insurer decided not to sell the policy again. Also, in some states, officials barred health plans that had been in effect before the health law but did not cover the law’s mandated benefits. In other states, federal rules allow these policies to continue through 2017.

Insurers have expressed concerns that if a consumer changes health plans, the federal website might not be able to notify their previous company and the consumer could get billed for both plans. Be sure to keep proof of payments in case you face this problem and watch your credit card or bank account credits to make sure you’re not being billed twice. A spokesman for the Centers for Medicare and Medicaid Services said the government is aware of the concerns and plans to give insurers lists of customers who have been automatically enrolled into a plan as well as consumers who chose to stay in the same plans. He said the government is also “examining options” on how to provide insurers the names of people who picked another plan during the enrollment period.

I want to buy health insurance but can’t afford it. What should I do?

Depending on your income, you might be eligible for Medicaid, the federal-state program for low-income people. Before the health law, in most states nonelderly adults without children didn’t qualify for Medicaid. But now, states have an option to let the federal government pay the cost of an expansion in the program so that anyone with an income at or lower than 138 percent of the federal poverty level, (about $16,105 for an individual or $32,913 for a family of four based on current guidelines) will be eligible for Medicaid. So far, 27 states and the District of Columbia have chosen to expand Medicaid.

What if I make too much money to qualify for Medicaid but still can’t afford to buy coverage?

You might be eligible for government subsidies to help you pay for private insurance sold in the insurance marketplaces.

These premium subsidies will be available for individuals and families with incomes between 100 percent and 400 percent of the poverty level, or about $11,670 to $46,680 for individuals and $23,850 to $95,400 for a family of four (based on current guidelines).

The subsidies are pegged to the federal poverty level and are most generous for those who make the least amount of money. They also require individuals to spend a certain percentage of their income before the subsidies kick in.

I didn’t get health insurance in 2014. What is going to happen to me now?

When you file your income taxes for 2014, you’ll be asked whether you have health insurance. Unless you qualify for an exemption, if you don’t have coverage you’ll have to pay a penalty of $95 or 1 percent of your income, whichever is higher. That amount will increase in 2015 to the larger of $325 per person or 2 percent of income.

What if I have health problems?

Insurers are no longer allowed to deny you coverage or charge you more based on a pre-existing medical condition. The law also eliminated annual and lifetime caps on coverage of essential health benefits, which include prescription drugs and hospitalization.

I get health coverage at work and want to keep my current plan.  Can I do that?

If you qualify for employer-provided coverage, you can stay in that plan.  But, just as before the law was passed, your employer is not obligated to keep your current plan and may change premiums, deductibles, co-pays and network coverage. Insurers can also change the plans they offer, so your employer may not be able to purchase the same plan it did a year ago.

I own a business.  Will I have to buy health insurance for my workers?

No employer is required to provide insurance, but large employers who don’t could face penalties.

Starting next year, employers with 100 or more employees that provide insurance must do so for 70 percent of workers rather than 95 percent as the law previously required. They will have to cover 95 percent of workers starting in 2016. This requirement applies to full-time workers, which are defined as those who work at least 30 hours per week.

Starting in 2016 – a two-year delay from the previous date of 2014 – businesses with 50 to 99 employees that don’t provide health care coverage and have at least one full-time worker who receives subsidized coverage in the health insurance exchange will have to pay a fee of $2,000 per full-time employee. The firm’s first 30 workers would be excluded from the fee.

Firms with fewer than 50 people don’t face any penalties.

In addition, if you own a small business and purchase insurance through a health exchange, the health law offers a tax credit to help cover the cost. Employers with fewer than 25 full-time workers who earn an average yearly salary of $50,000 or less can qualify. Employers must pay at least 50 percent of the individual worker’s premium cost to get the credit. Small business owners can purchase coverage on the Small Business Health Options Program, also known as the SHOP exchange.

What other parts of the health law are now in place?

You are likely to be eligible for some preventive services, such as blood pressure screenings and cholesterol tests, with no out-of-pocket costs.

Health plans can’t cancel your coverage if you get sick – a practice known as “rescission” – unless you committed fraud when you applied for coverage.

Insurers have to provide rebates to consumers if the companies spend less than 80 to 85 percent of premium dollars on medical care. According to the Department of Health and Human Services, since 2011 consumers have saved $9 billion on their health insurance premiums due to the provision. The agency also said that nationwide consumers saved $330 million in 2013 in refunds, with 6.8 million consumers due to receive an average benefit of $80 per family.

And, yes, children up to age 26 can still stay on their parents’ insurance. This was one of the most popular provisions of the new law.

Some plans that were in place when the law was passed and have not changed significantly do not have to abide by certain parts of the law. For example, these “grandfathered” plans can still charge beneficiaries part of the cost of preventive services.

Most plans are expected to change over time and lose grandfathered status.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Critics of America’s health care system say it’s really a “sick care” system. Doctors and hospitals only get paid for treating people when they’re sick.

But that’s starting to change. Health insurance companies and big government payers like Medicare are starting to reward doctors and hospitals for keeping people healthy.

So, many health care companies are trying to position themselves as organizations that help people stay well.

One of the latest is DaVita HealthCare Partners, a provider of kidney dialysis services. The company operates 2,152 dialysis centers in the U.S. and 87 in its fast-growing international buisiness.

DaVita is making a move into primary care, and it just announced a joint venture with a hospital company in Colorado and Kansas.

DaVita CEO Kent Thiry says it’s like changing the company from being an electrician into a general contractor. “And in so doing,” he says, “[We] have a much more comprehensive impact on how the house gets designed, how it gets built, how it gets maintained for the betterment of those who live in the house. That’s the simplest way to characterize the change.”

DaVita’s partner in the new venture is Centura Health, the biggest hospital company in Colorado. Like DaVita, it is also expanding aggressively into primary care and services beyond hospital-based procedures.

Centura CEO Gary Campbell says that in order for his company to keep people healthy, it needs the ability to crunch lots of health data. The idea is to use computer systems to keep track of peoples’ health, and flag health problems before they happen. He says DaVita HealthCare Partners is really good at that.

“Our physicians have gone scouring around the country, and believe that Health Care Partners really has the premier analytics.”

So, if DaVita wants to grow substantially beyond the current 168,000 dialysis patients it serves now, it needs to expand beyond just kidney care, says Mark Stephens with Prima Health Analytics. In 2012, the company started buying big doctors practices in several states. It’s hoping that its experience caring for very sick dialysis patients will help it manage family practices, and now, make hospitals more efficient.

Stephens also says DaVita might also be trying to create a model for Medicare to follow. That agency currently picks up the tab for about 85 percent of all Americans getting dialysis. He says Medicare has been offering dialysis companies opportunities to assume responsibility for those patients’ health care beyond dialysis, but that the companies haven’t found the deals attractive so far.

If DaVita’s new joint venture is successful, and it lowers the cost of care for both dialysis patients and those who aren’t as sick, the company may be able to win lots of new business from Medicare and private insurance companies.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.