Justia Legal Resources: Health Care Law Center

Medical concerns can be stressful enough without facing legal or financial problems related to them. However, health care consumers may have more rights and options than they realize. Justia provides a free resource to guide them.

Approximate Read Time: 4 Minutes

The health care system in the U.S. diverges from its counterparts in most developed countries. Private entities rather than the government generally take the lead in providing health care services to most Americans. However, the government still regulates certain areas of the industry, such as health insurance. Publicly funded programs Medicare and Medicaid also offer critical assistance in making medical services accessible to certain sectors of the population. The world of health care can be tricky to understand for the average person. The Health Care Law Center in the Justia Legal Guides provides some basic answers to questions that may arise when navigating this area.

Can I Get Health Insurance With a Pre-Existing Condition?

Yes, the Affordable Care Act (popularly known as Obamacare) generally prohibits insurers from withholding coverage to a consumer based on a pre-existing condition. This went further than the Health Insurance Portability and Accountability Act (HIPAA), which allowed some limits on coverage for pre-existing conditions. However, certain older plans called “grandfathered health plans” may not need to follow the Affordable Care Act rules.

What if I Disagree With My Health Insurer’s Decision?

A consumer might be able to resolve some simple problems like billing errors through customer service. For more complex disputes with an insurer, a consumer can ask for a formal explanation of the decision and then pursue an internal review according to the process provided by the insurer. A document called Evidence of Coverage will outline the rules that the consumer must follow. If the internal review process still doesn’t produce their desired result, they can resort to external dispute resolution methods, such as arbitration.

How Do Health Savings Accounts Work?

A health savings account (HSA) may be a cheaper alternative to a health insurance plan for some consumers. You can put money into the HSA tax-free, and it will cover future medical expenses for your family and you. You also will need to set up a high-deductible health insurance plan (HDHP), which has certain pros and cons. An HDHP has higher deductibles and out-of-pocket maximums, but a consumer will pay lower premiums and can funnel the money saved by reducing their fixed costs into the HSA. They will not be taxed on withdrawals from the HSA for qualified medical expenses.

Does My Employer Need To Provide Health Insurance?

Under the Affordable Care Act, a business with 50 or more full-time employees will face a penalty if it does not provide health insurance to at least 95 percent of those employees. The employer plan must cover any children of an employee who are under 26, including adopted children but not including stepchildren. It does not need to cover spouses. In addition, an employer must provide health insurance to an employee if it explicitly agrees to do this in an employment contract or a collective bargaining agreement. An employer cannot discriminate in providing insurance, such as excluding people of a certain race, national origin, age, or religion from benefits.

Will I Face a Penalty for Not Getting Health Insurance?

Probably not, unless you live in one of a small handful of states. You may have heard that the Affordable Care Act (Obamacare) has a provision called an individual mandate, which requires most people who do not get health insurance to pay a penalty. While the individual mandate remains in effect, Congress set the penalty at zero several years ago, so federal law no longer imposes any real consequence for not getting insurance. A few states have enacted their own individual mandates, though, for which violations may carry real penalties.

Can I Get My Child’s Medical Records?

The Health Information Portability and Accountability Act (HIPAA) governs access to medical records. This federal law generally allows a parent to get the medical records of their child, with certain exceptions. For example, a parent may not have a right to get the records when the child has consented to medical care to which the parent does not need to consent.

What Does Medicare Cover?

Medicare has three main components, known as Part A, Part B, and Part D. Part A focuses on hospital care, while Part B focuses on medically necessary services like doctor’s visits and lab tests, and Part D covers prescription medications. Each component has its own formula for the costs that a consumer must shoulder. If a consumer also gets Medicaid, they can use it to pay for some of these costs, such as the percentage of doctors’ bills that Part B of Medicare does not cover.

Who Qualifies for Medicaid?

Eligibility criteria for Medicaid vary by state. In general, though, a consumer will qualify for these benefits if they have a very low income, and they are over 65, pregnant, or living with a disability, breast cancer, or cervical cancer. If a woman who gets Medicaid gives birth to a child, they will be covered by Medicaid for the first year after their birth. Some state Medicaid programs extend to broader groups, such as people with low incomes who have children.

How Does Medicaid Reimbursement Work?

A state Medicaid program can try to get reimbursed from the estate of someone who received these benefits. However, Medicaid cannot get reimbursed if the recipient has a living spouse or a child who is under 21 or living with a disability. The program also may choose to waive its right to reimbursement in certain situations, such as when it would cause an undue hardship to the heirs of the recipient. People who think that they may eventually want to get Medicaid can try to prevent reimbursement by transferring their assets in advance, but this requires following certain rules.

What Does a Health Care Power of Attorney Do?

In a health care power of attorney, you can name another person to serve as your health care agent. This means that they will share your wishes with your health care providers if you cannot do this yourself. A health care agent may have additional powers in some cases, such as choosing doctors or getting medical records. Someone creating a health care power of attorney must comply with formal requirements to make the instrument enforceable. They can change it at any point if they still have capacity.

Final Thoughts

The health care sector can seem like a labyrinth, riddled with confusing language and unexpected obstacles. It’s critical to understand the full scope of your rights and options. If you have a specific question about a topic such as health care insurance, Medicare or Medicaid, or a health care power of attorney, you should consult a health care lawyer for advice tailored to your situation. In the meantime, the Health Care Law Center offers a readable overview of some key concepts in this area. Like the other Justia Legal Guides, it furthers our mission of making the law free and accessible to all.

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