Surprise Bills for Many Under Obamacare

Consumers with health coverage through the Affordable 
Care Act are facing surprise medical bills that sometimes 
exceed the caps on out of pocket expenses. Photo: Getty

Many consumers with health coverage through the Affordable Care Act are facing unexpected medical bills that in some cases greatly exceed the law’s caps on out-of-pocket expenses.

The law’s limits don’t apply to charges from out-of-network providers, and many insurance plans sold on ACA exchanges have limited networks—amplifying the risk of surprise bills.

Health plans offered by employers also have been slimming down the number of doctors and hospitals in their networks. But what have come to be known as narrow networks are more prevalent in plans offered on the health law’s exchanges, one tactic insurers are using to curtail costs because they can’t exclude consumers with existing medical conditions.

When Arturo Paramo, a 50-year-old construction worker, experienced chest pains last year, he was admitted to St. Francis Hospital in Bartlett, Tenn., after a doctor sent him there following an electrocardiogram. His wife, Bainey, said they weren’t told the hospital in suburban Memphis didn’t accept her family plan. They got a $22,945 bill—above the ACA’s $12,700 cap for a family plan in 2014—in the mail.

“It was out of network. Why didn’t they tell me when we entered? We would have gone to the right hospital,” said Ms. Paramo, a homemaker in nearby Arlington with four children.

The couple appealed the charge, which the hospital reduced to $600—but only after the bill had been sent to a collections agency, which Ms. Paramo worries will hurt the family’s credit rating.

Kelly Dignam of York, Maine, learned after getting a 
colonoscopy at Portsmouth Regional Hospital in NH that 
not all of the members of her medical team were in-network, 
resulting in unexpected medical bills. 
Photo: Dominick Reuter/WSJ

Under the ACA, patients generally can’t be charged higher coinsurance or copayments for out-of-network emergency-room services—but they can be charged for the amount insurance doesn’t cover, which could be thousands of dollars. The law caps out-of-pocket costs in 2015 at $6,600 for an individual and $13,200 for a family. But that doesn’t apply to out-of-network providers who charge patients for the part of bills that their insurance doesn’t pay.

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