Bill Of The Month Archives - �鶹Ů�� Health News

She Owed Her Insurer a Nickel, So It Canceled Her Coverage

Elisabeth Rosenthal — Mon, 30 Mar 2026 09:00:00 +0000

Last summer, Lorena Alvarado Hill received a series of unexpected medical bills.

A teacher’s aide in Melbourne, Florida, Hill is a single mom who works shifts at J.Crew on the weekends to send her daughter to college. Hill and her mother, who lives with her, had been enrolled in an insurance plan through HealthFirst.

Hill paid nothing toward the premiums for the government-subsidized plan, which previously had covered her scans and other appointments.

Then the bills came.

Hill was on the hook for a $2,966.93 MRI, as well as more than half a dozen doctor visits costing about $200 or $300 each. Without that kind of money on hand, Hill said, she put a few of the bills on payment plans and tried to figure out what had gone wrong.

She discovered, to her surprise, that her insurance had been canceled for “non-payment of premiums.”

The Medical Service

A health insurance plan purchased through the Affordable Care Act federal exchange, healthcare.gov.

The Bill

A monthly premium bill for 1 cent, which in the following months increased incrementally to 5 cents.

The Billing Problem: Small Bill, Big Consequences

Premium subsidies for ACA plans are automatically recalculated every time coverage is changed because of a life event, such as marriage, a change of job, or a child turning 26. In June, Hill removed her mother from the family’s group plan because she turned 65 and became eligible for Medicare and Medicaid.

The change triggered a recalculation of Hill’s monthly premium contribution, increasing it from $0 to 1 cent. She said she thought the amount was so small that she couldn’t pay it with her credit card.

Hill acknowledged she had received some bills that noted, “You may lose your health insurance coverage because you did not pay your monthly health insurance premium.”

But she said that her doctors collected the usual copayments during subsequent visits and that her insurance broker told her not to worry, reassuring her that the plan was “active.” Hill figured the 1-cent monthly premium was probably a rounding error that couldn’t result in termination, she said.

On Nov. 22, she got a letter marked “Important: Your health insurance coverage is ending.” It listed the last day of coverage as July 31, nearly four months before.

“I panicked,” Hill said. “I didn’t sleep that night.”

On Nov. 22, 2025, Hill got a letter informing her that her health insurance had been canceled — listing the last day of coverage as July 31. The terminated policy left her on the hook for thousands of dollars in bills. “I didn’t sleep that night,” she said. (Michelle Bruzzese for �鶹Ů�� Health News)

She made an appointment the next day with her broker, who called HealthFirst for clarification. The news was even worse: Not only had her insurance been canceled, but the 5-cent bill could be sent to a collection agency.

Hill takes out loans to pay her daughter’s college expenses. “I couldn’t have my credit ruined,” she said.

Others have lost their coverage over owing small amounts, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “This woman’s situation is not so unusual with the enhanced subsidies,” she said.

The American Rescue Plan, passed in 2021, increased the amount of government assistance available to ACA plan holders. Those enhanced subsidies, which Congress let expire at the end of last year, meant enrollees with lower incomes had to pay little or nothing toward their premiums.

The Biden administration found that, in 2023, about 81,000 subsidized ACA insurance policies were terminated because the enrollee owed $5 or less. Nearly 103,000 more were canceled for owing less than $10.

To prevent that kind of coverage loss, most likely hitting people with little income, Biden administration health officials to allow ACA enrollees to retain coverage if they owed less than $10, or less than 95% of premium costs.

Insurers were required to keep insurance active for a 90-day “grace period” to give enrollees time to respond. That’s why Hill’s doctors initially took her copayments and sent no bill, as if nothing had changed.

That Biden administration “flexibility” rule took effect Jan. 15, 2025, though not every insurer opted to offer leniency to those owing small amounts.

The Trump administration removed the rule on Aug. 25, eliminating the protection entirely in the name of combating fraud and abuse.

The Resolution

Alarmed by the cancellation, the thousands of dollars in bills, and the threat of collections over 5 cents, Hill researched insurance law and fought back.

She filed a complaint in December with HealthFirst and the Florida Department of Financial Services asking for a write-off of her 5-cent balance and retroactive restoration of her policy, citing state and federal laws that seemed to apply to her situation.

In particular, she wrote, “creditors are not required to collect, and consumers are not required to pay, credit-card balances of $1.00 or less,” adding that “all major insurers and payment processors in Florida follow a 1-cent write-off policy.”

She noted that HealthFirst’s policy was to respond to complaints in 30 days.

Thirty days came and went, but Hill said she heard nothing in response — and new bills from her canceled policy kept coming.

Despite her frustration, Hill said, all her doctors were contracted with HealthFirst, so she reenrolled for 2026.

Lance Skelly, a spokesperson for HealthFirst, initially said the case “is still in the appeals/grievance process.” In a follow-up email, he said HealthFirst had in canceling Hill’s policy.

“Stepping back from what’s legal, this is just ridiculous,” Corlette said.

Weeks after a reporter’s query to the insurer, Hill said she looked at her billing statements for all the medical services she received in 2025 and was pleasantly surprised that the balances owed had been adjusted to $0.

But she said she would also like HealthFirst to cover what she had paid and still owed toward the bills she’d put on payment plans.

Hill and her mother were enrolled together in a health plan purchased through the federal Affordable Care Act exchange. Hill removed her mother from the plan when she became eligible for Medicare and Medicaid, but the change triggered a recalculation of her monthly premium contribution, increasing it from $0 to 1 cent. She said the amount was so small that she couldn’t figure out how to pay for it with her credit card. (Michelle Bruzzese for �鶹Ů�� Health News)

The Takeaway

Even small bills can have major consequences.

With the automation of more health billing decisions, irrational results have become increasingly common.

“One cent?!” Hill said. “No human would do this!”

It can be tempting to dismiss the notice of a tiny debt, but it’s important to take it seriously. Contact the insurer and get a human involved.

And while insurance policies have grace periods allowing coverage to remain in place if you miss a payment, some are not very long. For subsidized ACA marketplace plans, the period is 90 days, but others last just 30 or 45.

Missing one payment can mean losing coverage. So it’s important to keep a close eye on premiums to make sure they’re paid.

Bill of the Month is a crowdsourced investigation by �鶹Ů�� Health News and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

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He Needs an Expensive Drug. A Copay Card Helped — Until It Didn’t.

Elisabeth Rosenthal — Fri, 27 Feb 2026 10:00:00 +0000

Over the course of 2025, Jayant Mishra of Mission Viejo, California, progressively developed scaly, itchy red patches on his skin. Then came the pain and swelling in the joints of his hands, making it difficult to do his work at a bank.

His primary care doctor referred him to a rheumatologist, who diagnosed psoriatic arthritis. She advised Mishra that while there’s no cure, there were many new medicines that could keep the autoimmune disease in check, and she recommended one, Otezla.

At first, Mishra balked. He knew the medicines were expensive. He worried about side effects. He thought he could manage with over-the-counter drugs.

But by September he was in so much pain that he agreed to try a starter pack provided by Otezla’s manufacturer, Amgen. It worked: The skin lesions disappeared, and the joint pain that kept him up at night dissipated. He was sold.

His rheumatologist got approval for the drug from his insurer, UnitedHealthcare, and signed him up for Amgen’s copayment assistance program. Having enrolled other patients, she told Mishra the copay card, similar to a credit card, should last a year, he said, shielding him from the drug’s high list price: around $5,000 for a 30-day supply, .

He said the doctor explained that, in her patients’ experience, insurers and their pharmacy benefit managers negotiated a deeply discounted price with Amgen — she estimated $1,400 to $2,200 a month. Patients paid a percentage of that amount, their “patient responsibility,” using the copay card.

Mishra said he was approved for a copay card covering $9,450 a year. “I was happy when I got the message,” he said.

He added that the doctor reassured him about the cost. “She said: ‘You shouldn’t have to pay anything out-of-pocket. Your copay card will cover this.’”

He started the medicine and, at first, paid nothing.

Then the bill came.

The Medical Service

Otezla, which comes in a pill, is approved to treat some autoimmune disorders, including psoriatic arthritis.

The Bill

$441.02, for the second month’s fill of the drug — before Mishra chose to ration rather than refill his prescription, because his copay card was empty.

The insurance statement from UnitedHealthcare’s pharmacy benefit manager, Optum Rx — another subsidiary of the same parent company, UnitedHealth Group — showed it did not provide a negotiated discount and covered just $308.34 of the full $5,253.85 charge for a 30-day supply. The charges for the second month depleted the copay card and left Mishra owing the balance.

The Billing Problem: Copay Card ‘Tug-of-War’

Copay assistance programs are part of a “tug-of-war between drug manufacturers and insurers,” said Aaron Kesselheim, a professor of medicine at Harvard Medical School who studies the pharmaceutical industry.

The value of drugmakers’ copay cards has become more unpredictable as insurers try to restrict their use. Many insurance plans, for instance, do not count the money from a copay program .

And patients who use a copay card can wind up paying full or nearly full price rather than the discounted rate negotiated by their insurer’s pharmacy benefit manager.

“When you purchased your medication a Manufacturer Coupon was used,” Mishra’s explanation of benefits statements read, in tiny letters. The amount the copay card covered “was not applied towards your Deductible and Out of Pocket Maximum.”

Caroline Landree, a spokesperson for UnitedHealthcare, said that “the copay card is an arrangement between the patient and the pharmacy. It is used outside of insurance.”

In an emailed statement, Elissa Snook, a spokesperson for Amgen, expressed a different view of who was responsible for Mishra’s dilemma: “Copay assistance programs are designed to help patients start and stay on prescribed therapy, but the value of that assistance can be exhausted more quickly when a health plan requires patients to pay the full list price of a medicine.”

Few patients can afford the list prices that pharmaceutical manufacturers charge in the United States for brand-name drugs.

Insurers insulate themselves and their customers from those higher prices through pharmacy benefit managers’ negotiated discounts. They might, for example, designate certain drugs as preferred medications for plan members in exchange for the manufacturer agreeing to a significant price reduction.

Manufacturers’ copay assistance programs offer another way for patients to avoid paying full price. The assistance is intended to encourage patients to choose an expensive, brand-name drug — not one that “treats the same condition that the insurer has gotten for a cheaper price,” said Fiona Scott Morton, an economist at the Yale School of Management who studies drug pricing.

The assistance also discourages patients from discussing with their doctor whether a cheaper, generic drug would do, drug industry researchers said.

While the Food and Drug Administration first approved a generic version of Otezla in 2021, Amgen has of its generic competitors, ensuring the brand-name drug has patent protection until 2028. Generic versions are available overseas and in Canada, where patients can purchase it in some cases for .

Mishra said one of his children joked he could cover a trip to visit relatives in India simply by purchasing his medicine while he was there.

The Resolution

Mishra has a health plan with a $5,000 deductible and contributes to a tax-free health savings account.

In September, he paid for the first month’s supply of Otezla with the copay card. But paying for October’s supply emptied the card — which he originally expected to last a year — and he said he used his HSA to pay for the roughly $400 that remained.

But wary of what the drug would cost in November and December, Mishra said, he tried to spread out the pills he had left from the starter pack and the first two months’ supply. He skipped some days and took only half of the prescribed dose to stretch the supply for two more months, knowing he would get a new copay card with the new year. Many of his symptoms returned, he said.

In January, he got another copay card, good for $9,450, which again wasn’t sufficient to pay for two months’ supply. He again paid the remaining balance in February from his HSA to count toward his $5,000 annual deductible. This time he owed $550, he said.

Mishra said his symptoms have resolved. With no clue what he’d be charged for March’s supply, he called UnitedHealthcare in late February and was told he would need to pay $4,450 for the month to meet his out-of-pocket maximum, he said.

But he said he pressed the representative further, asking why UnitedHealthcare doesn’t have a negotiated price. It does, they told him. “Actual price is $6,995.36.”

Mishra says his doctor reassured him that a copay card would cover his out-of-pocket costs for an expensive drug to treat psoriatic arthritis. But the assistance ran out much sooner than he’d expected. (Ariana Drehsler for �鶹Ů�� Health News)

The Takeaway

Copay cards and drugmaker programs that promise patients “you could pay $0” work in mysterious ways.

On the one hand, they encourage patients to use brand-name or expensive drugs that are off insurers’ formularies, or lists of preferred, covered drugs. On the other, many patients couldn’t afford prescribed medicines without them.

Patients with public insurance, such as Medicare and Medicaid, are not permitted to use the cards, because the government considers them an end run around its attempts to bring down drug spending.

Using a copay card has gotten trickier as insurers push back. First, patients need to understand whether there is an annual dollar or time limit on the card and how it works with their insurance. Otherwise, they risk ending up reliant on a drug they can’t afford.

Less expensive drugs often can suffice. For example, there are a number of medicines to treat psoriatic arthritis, some of which may be cheaper or have better coverage from a particular insurer. Patients should ask their doctors whether cheaper medicines will work.

It also can help patients to consider their prescriptions when they select a health plan. Landree, of UnitedHealthcare, said Mishra could have selected a plan for 2026 that would have covered Otezla for a $100 copay each month, though that would have meant a higher premium.

“Personally I’m not in financial distress — I can afford it,” Mishra said. “But it was sticker shock, and it just doesn’t seem right.”

Bill of the Month is a crowdsourced investigation by and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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Blurry Line Between Medical and Vision Insurance Leaves Patient With Unexpected Bill

Tony Leys — Fri, 30 Jan 2026 10:00:00 +0000

Barbara Tuszynski was concerned about her vision but confident in her insurance coverage when she went to an eye clinic last May.

The retiree, 70, was diagnosed with glaucoma in her right eye in 2019. She had a laser procedure to treat it in 2022, and she uses medicated drops in both eyes to prevent more damage. She is supposed to be checked regularly, she said.

During the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.

Tuszynski, who lives in central Wisconsin, had looked up beforehand whether the clinic in nearby Madison participated in her insurance plan. The insurer’s website listed the optometrist’s name with a green check mark and the words “in-network.” She assumed that meant her policy would cover the appointment.

Then the bill came.

The Medical Procedure

An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.

The Final Bill

$340, which included $120 for vision testing and $100 for optic nerve imaging.

The Billing Problem: Vision Coverage vs. Medical Coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the company’s denial letter said.

Tuszynski felt like she was seeing double. How could an eye doctor be in-network and out-of-network at the same time? She said she sent the insurer a screenshot of its own webpage showing the clinic listed as in-network.

She said that after she complained, UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic’s services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.

Tuszynski was baffled that care for a patient’s eyes would not be covered by vision insurance. She said she didn’t realize that insurers can have contracts with eye clinics to provide some services but not others.

UnitedHealthcare spokesperson Meg Sergel said such arrangements are common, including with non-Medicare insurance provided by employers or purchased by individuals. “I looked up my eye doctor, and it’s the same thing,” she said in an interview with �鶹Ů�� Health News.

Sergel said she understood how a customer could mistakenly think vision insurance would cover all care for the eyes. She said UnitedHealthcare recommends that before undergoing treatment, patients ask care providers whether they are in-network for specific services.

Otherwise, she said, to know whether a test or treatment is covered by vision insurance, “you’d have to read the nitty-gritty” of a policy.

Leaders at Steinhauer Family Eye Clinic, where Tuszynski saw the optometrist, declined to comment.

Casey Schwarz, senior counsel for education and federal policy at the nonprofit , said such complications frequently come up when Medicare Advantage members try to use their insurance at eye clinics or dental offices.

The federal government pays insurers to run Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries . Many offer routine vision and dental coverage that isn’t included with traditional Medicare.

“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around them,” Schwarz said.

The Resolution

After receiving the rejection letter, Tuszynski repeatedly contacted UnitedHealthcare to question the decision and filed an appeal with the company. Then, she said, she called to complain to federal officials. She also wrote to �鶹Ů�� Health News, which asked the insurer about the case.

UnitedHealthcare eventually agreed to cover the bill as if the service had been in-network. “In good faith, we made an exception,” Sergel said. However, Tuszynski was warned that if she received medical care from the clinic again, it would not be covered, because the clinic remains out-of-network for such services, Sergel said. “It doesn’t sound like that pleased her.”

Tuszynski confirmed that she is not pleased.

She said she lost sleep over the dispute and felt that it shouldn’t have taken so much effort to obtain a fair outcome. “It’s just been a horrible, difficult whirlwind,” she said.

The Takeaway

Schwarz said regulators should require insurance companies to clearly explain to customers and care providers how different procedures and services will be covered under vision, dental, and health plans. “They’re tricky,” she said.

In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye checkups, and hearing aids as basic health care that would be covered in the same way as other medical care. But until that happens, she said, patients with any doubt should call their insurers beforehand to check whether services will be covered.

Tricia Neuman, a senior vice president with �鶹Ů��, a health information nonprofit that includes �鶹Ů�� Health News, noted that Medicare’s website that can help people determine whether their doctors participate in a Medicare Advantage plan.

“This is helpful and a step forward, but information about provider networks is not always correct,” Neuman said. “Errors can come at a cost to enrollees, unless they are willing and able to take on their insurer.”

Tuszynski worked for 30 years as a secretary in hospitals and at doctors’ offices, so she’s familiar with billing issues, she said. “If I can’t sort through all this, how can anybody else do it?”

She knows her $340 bill was much smaller than the medical debts many other people face. But she said it was a serious amount of money to her, and she was glad she objected to the insurer’s contention that the bill shouldn’t be covered.

“I have a strong feeling about right and wrong — and this is just wrong,” she said.

Tuszynski was baffled that her Medicare Advantage plan did not cover her appointment at an eye clinic listed as in-network. Contesting the bill was frustrating, she says. “It’s just been a horrible, difficult whirlwind.” (David Nevala for �鶹Ů�� Health News)

For 2026, she decided to shift out of her Medicare Advantage plan. She now is enrolled in traditional Medicare, plus a supplemental plan to help with copays and other costs. She pays $184 a month for that plan, compared with paying no separate premium for her old Medicare Advantage plan.

Now she won’t have to worry about private insurers’ limited networks of contracted care providers, she said. Her glaucoma treatment will be covered at the Madison eye clinic.

However, she no longer has insurance coverage for eyeglasses, just a discount plan if she buys glasses from certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before switching. “Hopefully, those will last me a while,” she said.

Bill of the Month is a crowdsourced investigation by �鶹Ů�� Health News and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

This article/health-care-costs/medicare-advantage-eye-care-wisconsin-bill-of-the-month-january-2026/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

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Culture Wars Take Center Stage

Thu, 15 Jan 2026 20:20:00 +0000

The Host

Julie Rovner �鶹Ů�� Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of �鶹Ů�� Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

Millions of Americans are facing dramatically higher health insurance premium payments due to the Jan. 1 expiration of enhanced Affordable Care Act subsidies. But much of Washington appears more interested at the moment in culture war issues, including abortion and gender-affirming care.

Meanwhile, at the Department of Health and Human Services, personnel continue to be fired and rehired, and grants terminated and reinstated, leaving everyone who touches the agency uncertain about what comes next.

This week’s panelists are Julie Rovner of �鶹Ů�� Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Anna Edney Bloomberg News

Joanne Kenen Johns Hopkins University and Politico

Alice Miranda Ollstein Politico

Among the takeaways from this week’s episode:

Congress remains undecided on a deal to renew enhanced ACA premium subsidies, as it is on spending plans to keep the federal government running when the existing, short-term plan expires at the end of the month. While some of the bigger appropriations hang-ups are related to immigration and foreign affairs, there are also hurdles to passing spending for HHS.
ACA plan enrollment is down about 1.5 million compared with last year, with states reporting that many people are switching to cheaper plans or dropping coverage. Enrollment numbers are likely to drop further in the coming months as more-expensive premium payments come due and some realize they can no longer afford the plans they’re enrolled in.
A key Senate health committee on Wednesday hosted a hearing on the abortion pill mifepristone, focused on the safety concerns posed by abortion foes — though those concerns are unsupported by scientific research and decades of experience with the drug. Many abortion opponents are frustrated that the Trump administration has not taken aggressive action to restrict access to the abortion pill.
As the Trump administration moved this week to rehire laid-off employees and abruptly cancel, then restore, addiction-related grants, overall government spending is up, despite the administration’s stated goal of saving money by cutting the federal government’s size and activities. It turns out the churn within the administration is costing taxpayers more. And new data, revealing that more federal workers left on their own than were laid off last year, shows that a lot of institutional memory was also lost.

Also this week, Rovner interviews �鶹Ů�� Health News’ Elisabeth Rosenthal, who created the “Bill of the Month” series and wrote the latest installment, about a scorpion pepper, an ER visit, and a ghost bill. If you have a baffling, infuriating, or exorbitant bill you’d like to share with us, you can do that here.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The New York Times’ “,” by Maxine Joselow.

Alice Miranda Ollstein: ProPublica’s “,” by Anna Clark.

Joanne Kenen: The New Yorker’s “,” by Dhruv Khullar.

Anna Edney: MedPage Today’s “,” by Joedy McCreary.

Also mentioned in this week’s podcast:

The Washington Post’s “,” by Paul Kane.
HealthAffairs’ “,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin.
Politico’s “,” by Alice Miranda Ollstein.
JAMA’s “,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander.

click to open the transcript Transcript: Culture Wars Take Center Stage

Medical Bills Can Be Vexing and Perplexing. Here’s This Year’s Best Advice for Patients.

Emmarie Huetteman — Tue, 23 Dec 2025 10:00:00 +0000

A Texas boy’s cost over $1,400. A Pennsylvania woman’s cost more than $14,000.

Treatment for a Florida Medicaid enrollee’s cost nearly $78,000 — about as much as surgery for an uninsured Montana woman’s .

In 2025, these patients were among the hundreds who to investigate their medical bills as part of its “” series.

Insured and uninsured. Job-based and government-funded. Comprehensive and short-term. Part of a sharing ministry. So many people with different health insurance situations asked the same questions: Why do I owe so much? And how am I going to afford it?

As millions of Americans grapple with the rising cost of health insurance next year, the “Bill of the Month” series is approaching its eighth anniversary. Our nationwide team of health reporters has analyzed almost $7 million in medical charges, more than $350,000 of that this year.

Of this year’s 12 featured patients, five had their bills mostly or fully forgiven soon after we contacted the provider and insurer for comment.

Our mission, though, is to empower every patient with the information needed to understand, manage, and — if push comes to shove — fight their own medical bills. Here are our 10 takeaways from 2025.

1. Most insurance coverage doesn’t start immediately. Many new plans , so it’s important to maintain continuous coverage until the new plan kicks in. One exception: If you lose your job-based coverage, you have 60 days to opt into . Once you pay, the coverage applies retroactively, even for care received while you were temporarily uninsured.

2. Check out your coverage before you check in. Some plans come with unexpected restrictions, potentially affecting coverage for care ranging from contraception to immunizations and . Call your insurer — or, for job-based insurance, your human resources department or retiree benefits office — and ask whether there are exclusions for the care you need, including per-day or per-policy-period caps, and what you can expect to owe out-of-pocket.

3. “Covered” does not mean insurance will pay, let alone at in-network rates. Carefully read the fine print on network gap exceptions, prior authorizations, and other insurance approvals. The terms to certain doctors, services, and dates.

4. Get a cost estimate in writing for nonemergency procedures. If you object to the price, . And if you’re uninsured and receive a bill that’s $400 or more than the estimate, the federal Centers for Medicare & Medicaid Services has a .

5. Location matters. Prices can vary depending on where a patient receives care and where tests are performed. If you need blood work, ask your doctor to send the requisition to an in-network lab. A doctor’s office , for instance, may send samples to a hospital lab, which can mean higher charges.

6. When admitted, contact the billing office early. If possible, when you or a loved one has been hospitalized, it can help to speak to a billing representative. Ask whether the patient has been fully admitted or is being kept under observation status, as well as whether the care has been And while there may be no choice about , if a is recommended, you can ask whether the ambulance service is in-network.

7. Ask for a discount. Medical charges are almost always higher than what insurers would pay, because providers expect them to negotiate lower rates. You can, too. If you’re uninsured or underinsured, you may be eligible for a .

8. There’s help available for Medicaid patients. If you get a bill you , file a complaint with your state’s Medicaid program and, if you have one, your managed-care plan. Ask whether there is a caseworker who can advocate on your behalf. A legal aid clinic or consumer protection firm specializing in medical debt can also help file complaints and communicate with providers.

9. Your elected representatives can help, too. While a call from a state or federal lawmaker’s office may not get your bill forgiven, those officials often have with insurance companies, local hospitals, and other major providers — and advocating for you is their job.

10. When all else fails … you can !

Most Insurance Covers IUDs. Hers Cost More Than $14,000.

The Affordable Care Act requires most insurance plans to cover preventive care, including many forms of contraception, without cost to patients — but not if they’re “grandfathered” plans, which predate the law.

By Julie Appleby Jan. 31, 2025

A Runner Was Hit by a Car, Then by a Surprise Ambulance Bill

A San Francisco man had friends drive him to the hospital after he was hit by a car. Doctors checked him out, then sent him by ambulance to a trauma center — which released him with no further treatment. The ambulance bill? Almost $13,000.

By Sandy West Feb. 28, 2025

He Had Short-Term Health Insurance. His Colonoscopy Bill: $7,000.

After leaving his job to launch his own business, an Illinois man opted for a six-month health insurance plan. When he needed a colonoscopy, he thought it would cover most of the bill. Then he learned his plan’s limited benefits would cost him plenty.

By Julie Appleby March 28, 2025

The Patient Expected a Free Checkup. The Bill Was $1,430.

Carmen Aiken of Chicago thought their medical appointment would be covered because the Affordable Care Act requires insurers to pay for a long list of preventive services. But after the appointment, Aiken received a bill for more than $1,400.

By Samantha Liss and Lauren Sausser April 30, 2025

A Medicaid Patient Had a Heart Attack While Traveling. He Owed Almost $78,000.

Federal law says Medicaid must cover out-of-state emergency care. But a Florida man got a five-figure bill after a South Dakota hospital declined to charge his state’s Medicaid program.

By Arielle Zionts May 29, 2025

A Texas Boy Needed Protection From Measles. The Vaccine Cost $1,400.

A family living in Galveston was surprised to be charged thousands of dollars for immunizations for their children. Their insurance plan didn’t cover the shots, and the cost of the measles vaccine in particular was more than five times what health officials say it goes for in the private sector.

By Julie Appleby June 30, 2025

A Tourist Ended Up With a Wild Bat in Her Mouth — And Nearly $21,000 in Medical Bills

Health insurance generally doesn’t cover treatment for injuries sustained shortly before a customer buys a policy. A Massachusetts woman found that out the hard way.

By Tony Leys July 31, 2025

An Insurer Agreed To Cover Her Surgery. A Politician’s Nudge Got the Bills Paid.

A kindergartner in Missouri needed eye surgery. Her insurer granted approval for her to see a specialist nearby, yet her parents were confused when they still owed more than $13,000. Then her uncle, a former state senator, reached out to a colleague who contacted the hospital and the insurer.

By Cara Anthony Aug. 26, 2025

She Had a Broken Arm, No Insurance — And a $97,000 Bill

Deborah Buttgereit knew piecing together the broken bone in her elbow would be expensive. But complications the doctor deemed a surprise, midsurgery, drove the total bill tens of thousands of dollars above the original estimate.

By Katheryn Houghton Sept. 24, 2025

Doctor Tripped Up by $64K Bill for Ankle Surgery and Hospital Stay

A doctor in Colorado became the patient after an accident totaled her car and sent her to the operating room. The hospital kept her overnight, but her insurer stopped paying after she left the emergency room.

By Julie Appleby Oct. 29, 2025

Not Serious Enough To Turn on the Siren, Toddler’s 39-Mile Ambulance Ride Still Cost Over $9,000

After her son contracted a serious bacterial infection, an Ohio mother took the toddler to a nearby ER, and staffers there sent him to a children’s hospital in an ambulance. With no insurance, the family was hit with a $9,250 bill for the 40-minute ride.

By Tony Leys Nov. 25, 2025

Scorpion Peppers Caused Him ‘Crippling’ Pain. Two Years Later, the ER Bill Stung Him Again.

Homemade hot sauce sent a Colorado man to the emergency room with what he called “the worst pain of my life.” But stomach cramps were only the beginning. Two years later, the bill came.

By Elisabeth Rosenthal Dec. 19, 2025

Photographers

Jason Ardan
Scott Dalton
Loren Elliott
Jamie Kelter Davis
Matt Kile
Jacob Langston

Maddie McGarvey
Parker Michels-Boyce
Sophie Park
Jim Vondruska
Jeremy Wade Shockley
Rachel Woolf

Bill of the Month is a crowdsourced investigation by and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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Scorpion Peppers Caused Him ‘Crippling’ Pain. Two Years Later, the ER Bill Stung Him Again.

Elisabeth Rosenthal — Fri, 19 Dec 2025 10:00:00 +0000

Maxwell Kruzic said he was in such “crippling” stomach pain on Oct. 5, 2023, that he had to pull off the road twice as he drove himself to the emergency room at Mercy Regional Medical Center in Durango, Colorado. “It was the worst pain of my life,” he said.

Kruzic was seen immediately because hospital staff members were pretty sure he had appendicitis. They inserted an IV, called a surgeon, and sent him off for a scan to confirm the diagnosis.

But the scan showed a perfectly normal appendix and no problems in his abdomen. Doctors racked their brains for other possible diagnoses. Could it be a kidney stone? Gallstones? Here was a 37-year-old man in agony, but nothing really fit.

Then, someone asked what Kruzic had eaten the night before. He said he’d consumed tacos with some hot sauce that he’d made from a kind of scorpion pepper, grown from seeds he ordered from a chile pepper research institute.

The peppers measure over 2 million Scoville heat units on the spiciness scale, he noted, compared with a jalapeño at up to 8,000 or a habanero at 100,000 to 350,000.

The peppers are among “the world’s hottest, incredibly hot,” Kruzic said. “Delicious.” He loves spicy food and had never had a problem with it, but apparently this was just too much burn for his digestive system.

Kruzic spent much of the night on a gurney in the ER. After about four hours, the pain decreased, and he was sent home with medicine to treat nausea and vomiting.

Then the bill came — about two years later.

The Medical Procedure

Kruzic underwent blood work and a CT scan of his abdomen during his ER visit for acute abdominal pain.

Consuming very spicy foods painful inflammation and irritation of the digestive system. The discomfort typically resolves on its own.

The Final Bill

$8,127.41, including $5,820 for the CT scan. Kruzic paid $97.02 during his visit to the hospital, which was in-network under his insurance. After insurance payments and discounts, he owed $2,460.46 — the remainder of the $1,585.26 he owed toward his plan’s deductible and $972.22 he owed in coinsurance.

The Problem: Ghost Bills From Visits Past

This September, Kruzic received a bill for his pepper-induced ER visit in 2023.

Unfortunately for patients, there are no uniform rules for timely billing.

Anticipating a bill, Kruzic repeatedly checked the hospital’s online portal, as well as that of his insurer, UnitedHealthcare. He noted that the insurer said the claim had been processed shortly after his treatment. For about eight months, he kept checking the hospital portal’s billing section, which indicated he owed “$0.” He called UnitedHealthcare, and Kruzic said a representative assured him that if the hospital said he owed nothing, that was the case.

It is unclear what caused the nearly two-year delay. At least part of the problem seems to have involved protracted disagreements between the insurer and the hospital over how much his visit should have cost.

It took two years for Kruzic to get a bill for his October 2023 trip to the ER. There are no uniform rules requiring hospitals and other medical providers to bill patients in a timely manner after care. (Jeremy Wade Shockley for �鶹Ů�� Health News)

Lindsay Radford Foster, a spokesperson for CommonSpirit Health, the hospital system, said in a statement to �鶹Ů�� Health News: “United Healthcare, the insurer responsible for the medical claim, underpaid the account based on the care provided. As a result, CommonSpirit contacted UnitedHealthcare’s Payer Relations Department to rectify the underpayments.”

Asked why it had taken two years, she cited a reorganization at UnitedHealthcare and a change in the insurer’s representative assigned to the case.

But UnitedHealthcare contested that view. “This was paid accurately,” said Caroline Landree, a spokesperson for the insurer.

But those explanations don’t satisfy Kruzic, a geological consultant: “Receiving a bill two years after the service wouldn’t fly in any other industry. We could never contact a client two years after we completed a project and say, ‘By the way, we missed this charge.’”

“How could this be considered anything but surprise billing?” he added.

The federal No Surprises Act doesn’t protect against all types of medical bills that patients find surprising. It primarily protects patients from out-of-network charges when they visit an in-network hospital, or in an emergency.

But in medical billing, what’s legal and what’s reasonable are two very different issues.

“The bill certainly sounds outrageous,” said Maxwell Mehlmen, co-director of the Law-Medicine Center at the Case Western Reserve University School of Law. “The question is whether it’s legal.”

That, he said, “is a matter of state law and the terms of the insurance policy and the agreement between the hospital and the insurer.”

In Colorado, there are extensive regulations about how long health care providers have to file a claim and . For instance, claims for Medicaid patients must be filed from the date of service. For patients with private insurance, the terms may be outlined in their insurers’ contracts with individual providers.

If a hospital and the provider and insurer were working out payment in good faith, then a patient can be billed for their share of the costs years later.

The Resolution

Within hours of �鶹Ů�� Health News contacting the hospital’s media relations department for this article, Kruzic got a call from a hospital executive telling him his bill had been adjusted to zero.

Blaming administrative changes at the insurer, Radford Foster of CommonSpirit said that UnitedHealthcare had taken so long to properly pay the bill that the hospital couldn’t collect from the patient. She said that Kruzic’s statement balance “was to be adjusted to zero, but due to a clerical error, a statement was sent to the patient in error.”

UnitedHealthcare’s Landree said that “given the significant delay, we are addressing this issue directly with the physician’s office.”

“Mr. Kruzic will not be responsible for any additional costs related to this bill,” she said.

“Receiving a bill two years after the service wouldn’t fly in any other industry,” says Kruzic, who works as a geological consultant. “We could never contact a client two years after we completed a project and say, ‘By the way, we missed this charge.’” (Jeremy Wade Shockley for �鶹Ů�� Health News)

The Takeaway

�鶹Ů�� Health News’ “Bill of the Month” series receives complaints every year about ghost bills — bills that arrive long after a service is rendered.

Sometimes it’s because the insurer and hospital are haggling over payment, and the patient’s responsibility — usually a percentage of that number — can’t be calculated . Other times, insurers audit old bills and, determining they overpaid, try to claw back the money, resulting in the patient (or ) being billed for the difference.

For now, the legality of billing long after treatment depends primarily on the fine print of insurance contracts.

An insurer’s word that a claim has been “processed” doesn’t mean that the insurer has agreed to pay and that the billing is resolved. It could also mean that the insurer balked at the bill or completely denied payment.

As for Kruzic and his affinity for hot peppers? He said he still loves spicy food, but in his cooking, “I will not use scorpion peppers again.”

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Time’s Up for Expanded ACA Tax Credits

Thu, 18 Dec 2025 21:42:00 +0000

The Host

The enhanced premium tax credits that since 2021 have helped millions of Americans pay for insurance on the Affordable Care Act marketplaces will expire Dec. 31, despite a last-ditch effort by Democrats and some moderate Republicans in the House of Representatives to force a vote to continue them. That vote will happen, but not until Congress returns in January.

Meanwhile, the Department of Health and Human Services canceled a series of grants worth several million dollars to the American Academy of Pediatrics after the group again protested HHS Secretary Robert F. Kennedy Jr.’s changes to federal vaccine policy.

This week’s panelists are Julie Rovner of �鶹Ů�� Health News, Lizzy Lawrence of Stat, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Lizzy Lawrence Stat

Tami Luhby CNN

Alice Miranda Ollstein Politico

Among the takeaways from this week’s episode:

The House on Wednesday passed legislation containing several GOP health priorities, including policies that expand access to association health plans and lower the federal share of some Affordable Care Act exchange marketplace premiums. It did not include an extension of the expiring enhanced ACA premium tax credits — although, also on Wednesday, four Republicans signed onto a Democratic-led discharge petition forcing Congress to revisit the tax credit issue in January.
In vaccine news, the American Academy of Pediatrics spoke out against the federal government’s recommendation of “individual decision-making” when it comes to administering the hepatitis B vaccine to newborns — and HHS then terminated multiple research grants to the AAP. Meanwhile, the Centers for Disease Control and Prevention is funding a Danish study of the hepatitis B vaccine in West Africa through which some infants will not receive a birth dose, a strategy that critics are panning as unethical.
Also, a second round of personnel cuts at the Department of Veterans Affairs is expected to exacerbate an existing staffing shortage and further undermine care for retired service members.
The FDA is considering rolling back labeling requirements on supplements — a “Make America Health Again”-favored industry that is already lightly regulated.
And abortion opponents are pushing for the Environmental Protection Agency to add mifepristone to the list of dangerous chemicals the agency tracks in the nation’s water supply.

Also this week, Rovner interviews Tony Leys, who wrote the latest “Bill of the Month” feature, about an uninsured toddler’s expensive ambulance ride between hospitals.

Plus, for a special year-end “extra-credit” segment, the panelists suggest what they consider 2025’s biggest health policy themes:

Julie Rovner: The future of the workforce in biomedical research and health care.

Lizzy Lawrence: The politicization of science.

Tami Luhby: The systemic impacts of cuts to the Medicaid program.

Alice Miranda Ollstein: The resurgence of infectious diseases.

Also mentioned in this week’s podcast:

The Washington Post’s “.,” by Lena H. Sun and Paige Winfield Cunningham.
MedPage Today’s “,” by Jeremy Faust.
The Washington Post’s “,” by Meryl Kornfield, Hannah Natanson, and Lisa Rein.
NBC News’ “,” by Berkeley Lovelace Jr.
Politico’s “,” by Alice Miranda Ollstein and Ariel Wittenberg.
The Washington Post’s “,” by Paige Winfield Cunningham.
Politico’s “,” by Joanne Kenen.

Click to open the transcript Transcript: Time’s Up for Expanded ACA Tax Credits

Not Serious Enough To Turn on the Siren, Toddler’s 39-Mile Ambulance Ride Still Cost Over $9,000

Tony Leys — Tue, 25 Nov 2025 10:00:00 +0000

Elisabeth Yoder’s son, Darragh, was 15 months old in August when he developed what at first looked to his parents like hand, foot, and mouth disease. The common generally clears up in less than a week, but Darragh’s condition worsened over several days. His skin turned bright red. Blisters gave way to skin peeling off his face.

An online search of his symptoms suggested he had a serious bacterial infection. Yoder drove the toddler from their home in the small town of Mechanicsburg, Ohio, to the Mercy Health hospital in nearby Urbana.

Staff in the emergency room there quickly confirmed that Darragh had scalded skin syndrome and said he needed to be taken by a private company’s ambulance to Dayton Children’s, a hospital about 40 miles away.

“I asked them: ‘Can I take him? Can I drive him?’” Yoder said. “And they were like, ‘Oh, absolutely not.’”

So, Yoder and her son got into the ambulance, with Darragh strapped in his car seat. The ambulance driver didn’t turn on the siren or drive particularly fast, Yoder said. The trip took about 40 minutes, she said. “It was fairly straightforward transportation from Point A to Point B.”

Yoder had heard that ambulance rides can be pricey. But she didn’t know how much her son’s ride would cost.

Darragh was hospitalized for three days and recovered from the illness.

Then the bill came.

The Medical Procedure

During the ride, the ambulance crew monitored Darragh’s vitals and an intravenous line, inserted at the hospital, carrying fluids and antibiotics, but he received no other medical treatment, Yoder said.

The Final Bill

$9,250, which included a “base rate” charge of $6,600 for a “specialty care transport” and a mileage fee of $2,340, calculated at $60 for each of the ride’s 39 miles. It also included $250 for use of an intravenous infusion pump and $60 for monitoring Darragh’s blood oxygen.

The Problem: No Insurance, Few Protections

The children’s hospital charged only about $3,000 more for the toddler’s three-day stay than the ambulance company charged for the ride, Yoder said.

Darragh’s family doesn’t have health insurance, leaving them on the hook for the full charges. Their income is a bit too high for them to qualify for Medicaid, the public health program that covers low-income residents, or for the Ohio Children’s Health Insurance Program, which covers moderate-income kids.

The Yoders belong to a Christian health care sharing ministry, with members paying into a fund that helps reimburse them for medical bills.

Unlike health insurance, such arrangements do not offer members negotiated rates with ambulance companies or other medical providers. And there are no state or federal billing protections that would help an uninsured patient in Ohio with a ground ambulance bill.

Darragh’s family doesn’t have health insurance, leaving them on the hook for the full charges. Their income is a bit too high for them to qualify for Medicaid or for the Ohio Children’s Health Insurance Program. (Maddie McGarvey for �鶹Ů�� Health News)

The federal No Surprises Act protects those with insurance from large bills for air ambulance transportation provided outside their insurers’ network agreements. But by the law — and even if they were, that wouldn’t have helped the Yoders, since they didn’t have insurance.

Patricia Kelmar, the senior director of health care campaigns , a national advocacy group, said ambulance charges vary widely. She said she’s seen per-mile charges ranging from less than $30 to more than $80, as well as base rates that differ dramatically.

Some patients, such as those with traumatic injuries, need ambulances with highly trained staff and advanced medical equipment, Kelmar said, so it makes sense that those rides would be more expensive. But patients rarely are told what the ride will cost until they receive a bill.

Jennifer Robinson, a spokesperson for Mercy Health, said she couldn’t comment on a specific patient’s case but said the staff follows established medical standards. “When a patient requires a higher level of treatment, ambulance transfer between facilities is best practice to ensure appropriate care,” she said in an email to �鶹Ů�� Health News.

Kimberly Godden, a vice president for the ambulance company, Superior Ambulance Service, said a doctor at the first hospital requested a high-level transport for the patient, requiring specially trained staff.

“Our priority is always to ensure patients receive the highest-quality care when they need it most, and we respond to every call regardless of a patient’s ability to pay,” Godden said in an email. “Superior had the team and resources available to quickly and safely move the patient to the higher level of care they needed within the time frame set by the ordering physician.”

Godden said the company would offer a “charity care” rate to Yoder if the family qualified for it.

The Resolution

Yoder said she repeatedly discussed the bill with ambulance company representatives, including the option for charity care. They told Yoder the best deal they could offer was to reduce the total by about 40%, to $5,600, if the family paid it in a lump sum, she said.

After months of discussion, the family wound up agreeing to that deal, Yoder said. They put the charge on a new credit card, which gave them 17 months to pay it off with no interest.

They have agreed to payment plans with the two hospitals, which offered charity care discounts that dropped the bills to a total of about $6,800.

The Yoders expect the sharing ministry to reimburse them for about 75% of the payments they’re making to the hospitals and the ambulance service.

The Takeaway

Patients and their families should feel comfortable asking hospital staffers whether a recommended ambulance company is in their insurance network and how much the ride to another location will cost, said Kelmar, a national expert on such bills. “Shouldn’t the hospital know that?” she said. “I don’t think it’s that heavy of a lift.”

Kelmar said she doesn’t want to discourage people from taking an ambulance if a doctor says it’s necessary. Once consumers receive a bill for the service, she said, they often can negotiate the price down. It can help to look up what the ambulance service accepts as payment from government programs. Those rates are often much lower than the full-price charges patients see on a bill.

If the family had been covered by Ohio’s Medicaid program, the ambulance service would have been paid much less than it charged the Yoders. The public health program pays ambulance services for “specialty care transports,” plus $5.05 per mile. Those rates would have added up to $609.95 for the transportation part of Darragh’s ambulance ride.

Yoder said she wishes she had driven Darragh straight to the children’s hospital. If she had skipped the local ER, she said, they would have arrived at the bigger hospital sooner and she would have saved thousands of dollars.

But she didn’t feel as if she had a choice about putting her son in the ambulance, she said. The doctor told her it was necessary, and the hospital staff had already inserted an intravenous line. “I wasn’t going to pull out his IV line and just leave,” she said.

Yoder said she remains uninsured because she hasn’t seen any private insurance options that suit her family’s circumstances. No matter who pays the ambulance bill, she thinks the charges were much too high. She understands that patients can often negotiate discounts, she said, “but you shouldn’t have to work so hard for it.”

Yoder with her son, Darragh. (Maddie McGarvey for �鶹Ů�� Health News)

This article/health-care-costs/short-nonurgent-ambulance-ride-surprise-bill-of-the-month-november-2025/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

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The Government Is Open

Thu, 13 Nov 2025 18:45:44 +0000

The Host

Emmarie Huetteman �鶹Ů�� Health News Emmarie Huetteman, senior editor, oversees a team of Washington reporters, as well as “Bill of the Month” and “What the Health? From �鶹Ů�� Health News.” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.

The longest federal government shutdown in history is over, after a handful of House and Senate Democrats joined most Republicans in approving legislation that funds the government through January. Despite Democrats’ demands, the package did not include an extension of the expanded tax credits that help most Affordable Care Act enrollees afford their plans — meaning most people with ACA plans are slated to pay much more toward their premiums next year.

Also, new details are emerging about the Trump administration’s efforts to use the Medicaid program — for low-income and disabled people — to advance its immigration and trans health policy goals. And President Donald Trump has unveiled deals with two major pharmaceutical companies designed to increase access to weight loss drugs for some Americans.

This week’s panelists are Emmarie Huetteman of �鶹Ů�� Health News, Anna Edney of Bloomberg News, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

Panelists

Anna Edney Bloomberg News

Shefali Luthra The 19th

Sandhya Raman CQ Roll Call

Among the takeaways from this week’s episode:

Though the shutdown deal did not include an extension of the enhanced ACA subsidies, it came with a plan for a Senate vote by next month — on what exactly, it is unclear. Senate Republicans appear to be coalescing around providing money via health savings accounts rather than through the subsidies, while House Republicans seem more fragmented. The clock is ticking; the existing credits expire on Jan. 1, and open enrollment has begun.
Even as the Trump administration is likely to be tied up in court over its efforts to use Medicaid to crack down on health care for immigrants and trans people, they’ve had a real chilling effect. Immigrants, for instance, are skipping medical care, and hospitals are cutting back on offering gender-affirming care for trans people for fear of losing federal funding.
Trump’s newly announced GLP-1 price deals could help Medicare enrollees afford the weight loss drugs, potentially opening up access to a new population of patients — and customers. And a steady stream of policy reversals, unexplained dismissals, and negative news coverage is leading to worries that the FDA’s credibility is being undermined by internal drama. Also in question is whether it’s interfering with the agency’s work. Drug companies would likely say yes, and some within the FDA are trying to combat these concerns.
A major anti-abortion group is leaning into the current electoral moment, targeting key states and preparing for sizable political contributions ahead of next year’s midterm elections. Abortion opponents see an opportunity to capitalize on voters’ changing motivations and reposition themselves to fit into the post-Trump Republican Party.

Also this week, �鶹Ů�� Health News’ Julie Rovner interviews �鶹Ů�� Health News’ Julie Appleby, who wrote the latest “” feature, about a doctor who became the patient after a car accident sent her to the hospital — and $64,000 into debt. Do you have an outrageous medical bill? !

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Emmarie Huetteman: �鶹Ů�� Health News’ “,” by Amanda Seitz.

Anna Edney: Bloomberg News’ “,” by Tim Loh, Hayley Warren, and Julia Janicki.

Shefali Luthra: The 19th’s “,” by Orion Rummler.

Sandhya Raman: BBC’s “,” by Nadine Yousif.

Also mentioned in this week’s episode:

�鶹Ů��’s “,” by Audrey Kearney, Alex Montero, Mardet Mulugeta, Ashley Kirzinger, and Liz Hamel.
�鶹Ů�� Health News’ “,” by Phil Galewitz.
NPR’s “,” by Selena Simmons-Duffin.
Stat’s “,” by Lizzy Lawrence and Adam Feuerstein.
Stat’s “,” by Lizzy Lawrence.

Click to open the transcript Transcript: The Government Is Open

Doctor Tripped Up by $64K Bill for Ankle Surgery and Hospital Stay

Julie Appleby — Wed, 29 Oct 2025 09:00:00 +0000

Physician Lauren Hughes was heading to see patients at a clinic about 20 miles from her Denver home in February when another driver T-boned her Subaru, totaling it. She was taken by ambulance to the closest hospital, Platte Valley Hospital.

A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians recommended immediate surgical repair, she said.

“They said: ‘You have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she said. “As a clinician, I thought, ‘Yes.’”

She was taken to the operating room in the early evening, then admitted to the hospital overnight.

A friend took her home the next day.

Then the bills came.

The Medical Procedure

Surgeons cleaned the cut on her right knee, which had hit her car’s dashboard, and realigned a broken bone in her right ankle, stabilizing it with metal screws. Surgery is typically recommended when a broken bone is deemed unlikely to heal properly with only a cast.

The Final Bill

$63,976.35, charged by the hospital — which was not in-network with the insurance plan she got through her job — for the surgery and overnight stay.

The Problem: Should I Stay or Should I Go?

Hughes’ insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER but denied the surgery and overnight stay charges from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes said. “Just to stay there overnight. It’s crazy.”

Insurers have broad power to determine — that is, what is needed for treatment, diagnosis, or relief. And that decision affects whether and how much they will pay for it.

Four days after her surgery, Anthem notified Hughes that after consulting clinical guidelines for her type of ankle repair, its reviewer determined it was not medically necessary for her to be fully admitted for an inpatient hospital stay.

If she had needed additional surgery or had other problems, such as vomiting or a fever, an inpatient stay might have been warranted, according to the letter. “The information we have does not show you have these or other severe problems,” it said.

To Hughes, the notion that she should have left the hospital was “ludicrous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When she asked for further details about medical necessity determinations, Hughes was directed deep inside her policy’s benefit booklet, which outlines that, for a hospital stay, documentation must show “safe and adequate care could not be obtained as an outpatient.”

It turns out the surgery charges were denied because of an insurance contract quirk. Under Anthem’s agreement with the hospital, all claims for services before and after a patient is admitted are approved or denied together, said Anthem spokesperson Emily Snooks.

A hospital stay is not generally required after ankle surgery, and the insurer found Hughes did not need the kind of “comprehensive, complex medical care” that would necessitate hospitalization, Snooks wrote in an email to �鶹Ů�� Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”

Facing bills from an out-of-network hospital where she was taken by emergency responders, though, Hughes did not understand why she wasn’t shielded by the , which took effect in 2022. The federal law requires insurers to cover out-of-network providers as though they are in-network when patients receive emergency care, among other protections.

“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”

There was one more oddity in her case. During one of many calls Hughes made trying to sort out her bill, an Anthem representative told her that things might have been different had the hospital billed for her hospitalization as an overnight “observation” stay.

Generally, that’s when patients are kept at a facility so staff can determine whether they need to be admitted. Rather than being tied to the stay’s duration, the designation mainly reflects the intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for an observation stay than admission, Fiedler said.

That distinction is a big issue for patients on Medicare. Most often, the government health program will not pay for if the patient was not first formally admitted to a .

“It’s a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler said.

(Rachel Woolf for �鶹Ů�� Health News)

The Resolution

As a physician and a director of a health policy center at the University of Colorado, Hughes is a savvier-than-usual policyholder. Yet even she was frustrated during the months spent going back and forth with her insurer and the hospital — and worried when it looked like her account would be sent to a collection agency.

In addition to appealing the denied claims, she sought the help of her employer’s human resources department, which contacted Anthem. She also , which contacted Anthem and the Platte Valley Hospital.

In late September, Hughes received calls from a hospital official, who told her they had “downgraded the level of care” the hospital billed her insurance for and resubmitted the claim to Anthem.

In a written statement to �鶹Ů�� Health News, Platte Valley Hospital spokesperson Sara Quale said that the facility “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously sent Hughes a bill before working out the balance with Anthem, she wrote.

“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”

Anthem spokesperson Stephanie DuBois said in an email that Platte Valley resubmitted Hughes’ bill to the insurer on Oct. 3, this time for “outpatient care services.”

An explanation of benefits that was sent to Hughes shows the hospital rebilled for around $61,000 — about $40,000 of which was knocked off the total by an Anthem discount. The insurer paid the hospital nearly $21,000.

In the end, Hughes owed only a $250 copayment.

The Takeaway

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, in particular during a phase that may be nearly indistinguishable to the patient, known as “post-stabilization.”

Generally, that occurs when the medical provider determines the patient is to an in-network facility using nonmedical transport, said Jack Hoadley, a research professor emeritus at the McCourt School of Public Policy at Georgetown University.

If the patient prefers to stay put for further treatment, the out-of-network provider must then ask the patient , agreeing to waive billing protections and continue treatment at out-of-network rates, he said.

“It’s very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurer, in addition to asking the hospital’s billing department: Are you being fully admitted, or kept under observation status, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a key role in whether coverage is approved or denied, even after services are provided.

That said, Hughes did not recall being told she was stable enough to leave with nonmedical transportation, nor being asked to sign a consent form.

Her advice is to quickly and aggressively question insurance denials once they are received, including by asking for your case to be escalated to the insurer’s and hospital’s leadership. She said expecting patients to navigate complicated billing questions while in the hospital after a serious injury isn’t realistic.

“I was calling family,” Hughes said, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done — coming to grips with what just happened.”

This article/health-care-costs/doctor-ankle-surgery-hospital-stay-surprise-bill-of-the-month-october-2025/">article; first appeared on �鶹Ů��" rel="nofollow">">�鶹Ů�� Health News and is republished here under a

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She Owed Her Insurer a Nickel, So It Canceled Her Coverage

Khnkytjaw — Mon, 30 Mar 2026 09:00:00 +0000

Last summer, Lorena Alvarado Hill received a series of unexpected medical bills.

Hill paid nothing toward the premiums for the government-subsidized plan, which previously had covered her scans and other appointments.

Then the bills came.

She discovered, to her surprise, that her insurance had been canceled for “non-payment of premiums.”

The Medical Service

A health insurance plan purchased through the Affordable Care Act federal exchange, healthcare.gov.

The Bill

A monthly premium bill for 1 cent, which in the following months increased incrementally to 5 cents.

The Billing Problem: Small Bill, Big Consequences

Hill acknowledged she had received some bills that noted, “You may lose your health insurance coverage because you did not pay your monthly health insurance premium.”

On Nov. 22, she got a letter marked “Important: Your health insurance coverage is ending.” It listed the last day of coverage as July 31, nearly four months before.

“I panicked,” Hill said. “I didn’t sleep that night.”

Hill takes out loans to pay her daughter’s college expenses. “I couldn’t have my credit ruined,” she said.

That Biden administration “flexibility” rule took effect Jan. 15, 2025, though not every insurer opted to offer leniency to those owing small amounts.

The Trump administration removed the rule on Aug. 25, eliminating the protection entirely in the name of combating fraud and abuse.

The Resolution

Alarmed by the cancellation, the thousands of dollars in bills, and the threat of collections over 5 cents, Hill researched insurance law and fought back.

She noted that HealthFirst’s policy was to respond to complaints in 30 days.

Thirty days came and went, but Hill said she heard nothing in response — and new bills from her canceled policy kept coming.

Despite her frustration, Hill said, all her doctors were contracted with HealthFirst, so she reenrolled for 2026.

Lance Skelly, a spokesperson for HealthFirst, initially said the case “is still in the appeals/grievance process.” In a follow-up email, he said HealthFirst had in canceling Hill’s policy.

“Stepping back from what’s legal, this is just ridiculous,” Corlette said.

But she said she would also like HealthFirst to cover what she had paid and still owed toward the bills she’d put on payment plans.

The Takeaway

Even small bills can have major consequences.

With the automation of more health billing decisions, irrational results have become increasingly common.

“One cent?!” Hill said. “No human would do this!”

It can be tempting to dismiss the notice of a tiny debt, but it’s important to take it seriously. Contact the insurer and get a human involved.

Missing one payment can mean losing coverage. So it’s important to keep a close eye on premiums to make sure they’re paid.

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He Needs an Expensive Drug. A Copay Card Helped — Until It Didn’t.

Khnerich — Fri, 27 Feb 2026 10:00:00 +0000

At first, Mishra balked. He knew the medicines were expensive. He worried about side effects. He thought he could manage with over-the-counter drugs.

Mishra said he was approved for a copay card covering $9,450 a year. “I was happy when I got the message,” he said.

He added that the doctor reassured him about the cost. “She said: ‘You shouldn’t have to pay anything out-of-pocket. Your copay card will cover this.’”

He started the medicine and, at first, paid nothing.

Then the bill came.

The Medical Service

Otezla, which comes in a pill, is approved to treat some autoimmune disorders, including psoriatic arthritis.

The Bill

$441.02, for the second month’s fill of the drug — before Mishra chose to ration rather than refill his prescription, because his copay card was empty.

The Billing Problem: Copay Card ‘Tug-of-War’

The value of drugmakers’ copay cards has become more unpredictable as insurers try to restrict their use. Many insurance plans, for instance, do not count the money from a copay program .

And patients who use a copay card can wind up paying full or nearly full price rather than the discounted rate negotiated by their insurer’s pharmacy benefit manager.

Caroline Landree, a spokesperson for UnitedHealthcare, said that “the copay card is an arrangement between the patient and the pharmacy. It is used outside of insurance.”

Few patients can afford the list prices that pharmaceutical manufacturers charge in the United States for brand-name drugs.

The assistance also discourages patients from discussing with their doctor whether a cheaper, generic drug would do, drug industry researchers said.

Mishra said one of his children joked he could cover a trip to visit relatives in India simply by purchasing his medicine while he was there.

The Resolution

Mishra has a health plan with a $5,000 deductible and contributes to a tax-free health savings account.

But he said he pressed the representative further, asking why UnitedHealthcare doesn’t have a negotiated price. It does, they told him. “Actual price is $6,995.36.”

The Takeaway

Copay cards and drugmaker programs that promise patients “you could pay $0” work in mysterious ways.

Patients with public insurance, such as Medicare and Medicaid, are not permitted to use the cards, because the government considers them an end run around its attempts to bring down drug spending.

“Personally I’m not in financial distress — I can afford it,” Mishra said. “But it was sticker shock, and it just doesn’t seem right.”

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Blurry Line Between Medical and Vision Insurance Leaves Patient With Unexpected Bill

Khntonyl — Fri, 30 Jan 2026 10:00:00 +0000

Barbara Tuszynski was concerned about her vision but confident in her insurance coverage when she went to an eye clinic last May.

During the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.

Then the bill came.

The Medical Procedure

An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.

The Final Bill

$340, which included $120 for vision testing and $100 for optic nerve imaging.

The Billing Problem: Vision Coverage vs. Medical Coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the company’s denial letter said.

Otherwise, she said, to know whether a test or treatment is covered by vision insurance, “you’d have to read the nitty-gritty” of a policy.

Leaders at Steinhauer Family Eye Clinic, where Tuszynski saw the optometrist, declined to comment.

“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around them,” Schwarz said.

The Resolution

Tuszynski confirmed that she is not pleased.

She said she lost sleep over the dispute and felt that it shouldn’t have taken so much effort to obtain a fair outcome. “It’s just been a horrible, difficult whirlwind,” she said.

The Takeaway

“I have a strong feeling about right and wrong — and this is just wrong,” she said.

Now she won’t have to worry about private insurers’ limited networks of contracted care providers, she said. Her glaucoma treatment will be covered at the Madison eye clinic.

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Culture Wars Take Center Stage

Terry Byrne — Thu, 15 Jan 2026 20:20:00 +0000

The Host

Panelists

Anna Edney Bloomberg News

Joanne Kenen Johns Hopkins University and Politico

Alice Miranda Ollstein Politico

Among the takeaways from this week’s episode:

Congress remains undecided on a deal to renew enhanced ACA premium subsidies, as it is on spending plans to keep the federal government running when the existing, short-term plan expires at the end of the month. While some of the bigger appropriations hang-ups are related to immigration and foreign affairs, there are also hurdles to passing spending for HHS.
ACA plan enrollment is down about 1.5 million compared with last year, with states reporting that many people are switching to cheaper plans or dropping coverage. Enrollment numbers are likely to drop further in the coming months as more-expensive premium payments come due and some realize they can no longer afford the plans they’re enrolled in.
A key Senate health committee on Wednesday hosted a hearing on the abortion pill mifepristone, focused on the safety concerns posed by abortion foes — though those concerns are unsupported by scientific research and decades of experience with the drug. Many abortion opponents are frustrated that the Trump administration has not taken aggressive action to restrict access to the abortion pill.
As the Trump administration moved this week to rehire laid-off employees and abruptly cancel, then restore, addiction-related grants, overall government spending is up, despite the administration’s stated goal of saving money by cutting the federal government’s size and activities. It turns out the churn within the administration is costing taxpayers more. And new data, revealing that more federal workers left on their own than were laid off last year, shows that a lot of institutional memory was also lost.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The New York Times’ “,” by Maxine Joselow.

Alice Miranda Ollstein: ProPublica’s “,” by Anna Clark.

Joanne Kenen: The New Yorker’s “,” by Dhruv Khullar.

Anna Edney: MedPage Today’s “,” by Joedy McCreary.

Also mentioned in this week’s podcast:

The Washington Post’s “,” by Paul Kane.
HealthAffairs’ “,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin.
Politico’s “,” by Alice Miranda Ollstein.
JAMA’s “,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander.

click to open the transcript Transcript: Culture Wars Take Center Stage

Medical Bills Can Be Vexing and Perplexing. Here’s This Year’s Best Advice for Patients.

Khnkytjaw — Tue, 23 Dec 2025 10:00:00 +0000

A Texas boy’s cost over $1,400. A Pennsylvania woman’s cost more than $14,000.

Treatment for a Florida Medicaid enrollee’s cost nearly $78,000 — about as much as surgery for an uninsured Montana woman’s .

In 2025, these patients were among the hundreds who to investigate their medical bills as part of its “” series.

Of this year’s 12 featured patients, five had their bills mostly or fully forgiven soon after we contacted the provider and insurer for comment.

10. When all else fails … you can !

Most Insurance Covers IUDs. Hers Cost More Than $14,000.

By Julie Appleby Jan. 31, 2025

A Runner Was Hit by a Car, Then by a Surprise Ambulance Bill

By Sandy West Feb. 28, 2025

He Had Short-Term Health Insurance. His Colonoscopy Bill: $7,000.

By Julie Appleby March 28, 2025

The Patient Expected a Free Checkup. The Bill Was $1,430.

By Samantha Liss and Lauren Sausser April 30, 2025

A Medicaid Patient Had a Heart Attack While Traveling. He Owed Almost $78,000.

Federal law says Medicaid must cover out-of-state emergency care. But a Florida man got a five-figure bill after a South Dakota hospital declined to charge his state’s Medicaid program.

By Arielle Zionts May 29, 2025

A Texas Boy Needed Protection From Measles. The Vaccine Cost $1,400.

By Julie Appleby June 30, 2025

A Tourist Ended Up With a Wild Bat in Her Mouth — And Nearly $21,000 in Medical Bills

Health insurance generally doesn’t cover treatment for injuries sustained shortly before a customer buys a policy. A Massachusetts woman found that out the hard way.

By Tony Leys July 31, 2025

An Insurer Agreed To Cover Her Surgery. A Politician’s Nudge Got the Bills Paid.

By Cara Anthony Aug. 26, 2025

She Had a Broken Arm, No Insurance — And a $97,000 Bill

By Katheryn Houghton Sept. 24, 2025

Doctor Tripped Up by $64K Bill for Ankle Surgery and Hospital Stay

By Julie Appleby Oct. 29, 2025

Not Serious Enough To Turn on the Siren, Toddler’s 39-Mile Ambulance Ride Still Cost Over $9,000

By Tony Leys Nov. 25, 2025

Scorpion Peppers Caused Him ‘Crippling’ Pain. Two Years Later, the ER Bill Stung Him Again.

Homemade hot sauce sent a Colorado man to the emergency room with what he called “the worst pain of my life.” But stomach cramps were only the beginning. Two years later, the bill came.

By Elisabeth Rosenthal Dec. 19, 2025

Photographers

Jason Ardan
Scott Dalton
Loren Elliott
Jamie Kelter Davis
Matt Kile
Jacob Langston

Maddie McGarvey
Parker Michels-Boyce
Sophie Park
Jim Vondruska
Jeremy Wade Shockley
Rachel Woolf

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Scorpion Peppers Caused Him ‘Crippling’ Pain. Two Years Later, the ER Bill Stung Him Again.

Khnerich — Fri, 19 Dec 2025 10:00:00 +0000