On Christmas Day at the WaTiki indoor water park, Hans Wirt was getting winded from following his son up the stairs to the waterslides.

Wirt’s breathing became more labored once they returned to the nearby hotel where they and Wirt’s girlfriend were staying while visiting family in Rapid City, South Dakota.

Then he grew nauseated and went pale. Wirt thought the cause might have been the altitude change between his home in Deltona, Florida — 33 feet above sea level — and Rapid City, at the edge of the Black Hills. But his 12-year-old son was worried and called for an ambulance.

“I could tell by the look in his eyes that there was something a little more to this,” Wirt said. “So I can kind of thank my son for saving my life.”

It turned out the 62-year-old was having a heart attack. A “lousy Christmas present,” Wirt said.

Medics stabilized Wirt before taking him to Monument Health — the only hospital in Rapid City with an emergency room — where he was treated over two days.

Then the bill came.

The Medical Procedure

Paramedics used a defibrillator to restore a normal heart rhythm. Doctors at the hospital gave Wirt various medications, used an electrocardiograph and other diagnostic and monitoring devices, and inserted stents into his arteries to improve blood flow to his heart.

The Final Bill

$95,523.73, including $32,998.90 for medical supplies, mostly related to the stents, and $28,879 for treatment in a cardiac catheterization lab. After unspecified hospital adjustments to the bill, Wirt owed $77,574.44.

The Billing Problem: Medicaid Across State Lines

Wirt is covered by Florida’s Medicaid program through Sunshine Health, a managed-care plan. But the South Dakota hospital refused to submit the bill to his out-of-state Medicaid plan, instead sending it to Wirt and eventually threatening to send the debt to a collection agency.

Medicaid, the government health insurance program primarily for low-income people and those with disabilities, is jointly funded by the federal government and states. States are responsible for administering Medicaid, and most contract with private insurance companies like Sunshine Health.

Federal law says state Medicaid programs must reimburse out-of-state hospitals for beneficiaries’ care in an emergency.

Many hospitals bill out-of-state Medicaid plans in such situations. If they don’t, they risk not being reimbursed at all, since Medicaid recipients probably won’t be able to afford large bills, said Katy DeBriere, who was legal director for the Florida Health Justice Project when she spoke with KFF Health News in April.

But there’s no federal law that requires them to do so, she said.

Federal court opinions have noted that hospitals are not required to bill Medicaid for every individual beneficiary they treat, even if they generally accept Medicaid.

Monument Health didn’t bill Wirt’s insurance because the hospital isn’t enrolled as a health care provider with Florida Medicaid, said hospital spokesperson Stephany Chalberg. She told KFF Health News that Monument bills Medicaid plans only in South Dakota and four bordering states: Wyoming, Montana, Nebraska, and Minnesota.

The hospital’s website says Medicaid patients who are not enrolled in one of those states “are responsible for any charges.”

“Due to the significant credentialing requirements of our multiple hospitals and hundreds of physicians we do not participate with all states,” a hospital representative wrote in a message to Wirt.

According to Florida’s Medicaid website, out-of-state providers who have treated one of its enrollees must submit five documents to bill the program, including a six-page application, a copy of the provider’s license, and a claim form.

The process is different in each state, and many Medicaid programs reimburse out-of-state providers at lower rates than those that are in-state, according to the Medicaid and CHIP Payment and Access Commission, a federal agency that advises Congress.

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More from Bill of the Month

Provider enrollment barriers leave “beneficiaries in an untenable situation, preventing them from accessing the coverage to which they are legally entitled,” Chalberg said.

Wirt decided to submit his bill to his Medicaid plan on his own. But he said Sunshine Health told him it can only process bills received directly from providers.

Elizabeth Boyd, a spokesperson for Sunshine Health, told KFF Health News that its staff contacted the hospital on Wirt’s behalf. She did not respond when asked why the plan can’t process bills submitted by patients or what more it could have done to help Wirt.

The Resolution

A few days after KFF Health News emailed officials at Monument Health for this story, Wirt noticed his balance due fell from more than $77,000 to $0.

Chalberg told KFF Health News that Monument Health covered Wirt’s bill through its charity care program. She said that “appropriate patients” are told about the program and that “before any bill is sent to collections, it is evaluated to determine whether the patient may qualify for our financial assistance policy.”

To retain tax-exempt status, nonprofit hospitals must have programs that provide free or discounted care to patients who can’t afford their bills.

But Wirt said that when he first contacted Monument Health after receiving his bill and said he couldn’t afford to pay it, officials didn’t mention the program. He said they didn’t share any resources when he asked whether there were outside groups that could help him pay the bill. Wirt said hospital officials just recommended setting up a payment plan, but the monthly bills were still too high for him to afford. “There’s a reason why I’m on Medicaid,” Wirt said. “It’s just beyond me how they can expect somebody who had Medicaid to come up with that kind of money. It’s unrealistic.”

The Takeaway

Sarah Somers, legal director at the National Health Law Program, said the various “cogs in the Medicaid system” didn’t operate correctly in Wirt’s situation. “Nobody’s exerting themselves enough to just smooth the way for this person.”

States are responsible for managing Medicaid and are therefore the main “cog,” Somers said. She said Medicaid managed-care companies are also supposed to intervene.

Somers and DeBriere said Medicaid recipients who receive bills they don’t think they owe should file a complaint with their state’s Medicaid program and, if they have one, their managed-care plan. They can also ask whether there is a Medicaid or managed-care caseworker who can advocate on their behalf.

The attorneys said patients should also contact a legal aid clinic or a consumer protection firm that specializes in medical debt. DeBriere said those organizations can help file complaints and communicate with the hospital.

DeBriere said that, had she assisted Wirt, she would have immediately sent a letter to Monument Health ordering it to stop billing him and to either register with Florida Medicaid to submit his bill or offer him charity care.

Wirt said the doctors who treated him and the medical care he received at Monument Health were excellent. He said he spoke out about the hospital’s billing practices because he doesn’t want others to endure the same experience.

“If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state,” he joked.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being 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!

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

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

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The post A Medicaid Patient Had a Heart Attack While Traveling. He Owed Almost $78,000. appeared first on kffhealthnews.org

Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This content is primarily focused on health care issues, specifically problems encountered by Medicaid beneficiaries with out-of-state medical billing and insurance practices. It highlights the challenges faced by low-income and Medicaid patients in accessing affordable care and navigating complex administrative systems. The critique of hospital billing practices and Medicaid administration reflects concerns commonly associated with center-left perspectives, which emphasize stronger government oversight, expanded access to health care, and protections for vulnerable populations. However, the article maintains a factual, investigative tone without strong partisan language or advocacy, aligning it closer to a center-left rather than a far-left position.

ST. LOUIS — Kevin Hines has been living in a house without a roof in the days since a tornado devastated his community. He has seen some of his neighbors sleeping in their cars. A different man has spent untold hours on a bench.

In the aftermath of the May 16 tornado, Hines, 60, has a blue tarp covering his home. Still, rain came in three days later — an expected problem in a house without a roof. But he didn’t think wildlife would be an issue. Then a bird landed on his television. He spotted a squirrel on the sofa.

He already has enough to handle. He’s not sure when his home will be repaired. A toppled tree destroyed the purple Jeep he bought only months ago. His job told employees not to come into work because the building was damaged.

The tornado cut a 23-mile-long path, touching down in the affluent suburb of Clayton, Missouri, before ripping through the north side of the city of St. Louis then across the Mississippi River through communities in western Illinois. At least five people were killed, 38 more were injured, and about 5,000 structures were damaged, according to St. Louis Mayor Cara Spencer. The twister caused more than $1.6 billion in estimated property damage.

While the impact was felt throughout the area, it will take some neighborhoods longer than others to recover. Kayla Reed, a community activist who runs the Action St. Louis nonprofit, which is coordinating help for storm victims, said residents in the predominantly Black area known as North City especially face a long set of challenges in the days ahead.

“A natural disaster met a created one and a systemic one,” Reed said. “They’ve sort of been in a long-term storm all of their lives. If you live in this footprint, you know this is where infant mortality is highest. This is where incarceration rates are highest. This is where poverty rates are highest.”

Food and water aid provide some relief, Reed said, but the community needs more than that. “I can’t put into words how long it’s going to take to stabilize some of these families and how much trauma they are navigating,” she said.

A possible source of major aid is the federal government, which can unlock resources at the president’s discretion. But Missouri is already waiting for President Donald Trump to approve federal assistance for damage left by three sets of storms in March and April that killed 19 people in the state. Trump has denied major disaster requests from West Virginia and Washington this year, and initially denied one for storm and tornado damage in Arkansas before reversing course and approving the request May 13.

Black families here in North St. Louis are worried that their community will not be prioritized.

On May 19, Missouri Gov. Mike Kehoe, a Republican, requested that Trump issue a federal emergency declaration, which would authorize about $5 million in federal assistance for cleanup efforts. Kehoe also requested that the Federal Emergency Management Agency conduct a preliminary damage assessment, a necessary step to securing a “major disaster declaration,” which would provide federal resources for homeowners and renters, reimburse local government efforts, and pay for damaged public infrastructure.

FEMA was on the ground two days later helping conduct damage assessments. But a disaster declaration could take weeks, if it comes.

“Bringing FEMA in, it’s my understanding, is not going to be a quick process,” the mayor said at a May 21 press conference. “All elected officials at every level here are doing everything they can to make that process as quick as possible.”

That includes Republican U.S. Sen. Josh Hawley, who asked Homeland Security Secretary Kristi Noem during an oversight hearing May 20 to help expedite the pending aid requests from Missouri’s three previous storms and for the recent tornado. “Yes, absolutely,” she responded.

While the city waits, thousands of volunteers have shown up to the parking lot of the YMCA’s O’Fallon Park Rec Complex in North St. Louis in what they are calling the “People’s Response” to help residents in need. So far, they’ve helped more than 5,000 families. Volunteers have collected more than 17,280 pounds of food, according to Action St. Louis.

The last time such an outpouring occurred around here, according to locals, was in 2014 after the police killing of Michael Brown in nearby Ferguson. Rasheen Aldridge, an alderman who represents part of the storm-affected area, said some of the same activists who showed up then made it a point to help now.

Hines, too, looked for ways to help his neighbors. He became an unofficial traffic director at the YMCA as thousands of cars streamed into the area to get help — or provide it.

“It’s not about me,” Hines said. “I’m staying until no one is here because there’s nothing to do at my house. I have no power.”

Residents in North City described the moments after the storm as chaos: trees down everywhere; power lines damaged; limited cellphone service, making it hard to connect with loved ones. Then the sun went down, cloaking corners of the city in complete darkness.

Five days after the tornado, people still needed candles, flashlights, and batteries to make it through the night. Piles of debris filled street corners. Exterior walls were ripped off homes, exposing the inside of closets, bedrooms, and living rooms to passersby on the street. Some buildings were leveled. The downed trees in the tornado’s path left a scar in the city’s canopy visible from miles away.

The tornado flipped a semitrailer outside a new gas station and strip mall that had been scheduled to open this fall. One evening, Charles Stanford, a security guard for the property, sat in the parking lot to make sure no one tried to enter what remained of the building. Stanford said the project had been nearly complete. Now, it is surrounded by rubble and debris.

A giant tree crashed into the house of one of Hines’ neighbors. He said the woman recently had heart surgery and had been recovering at home. But then she went back to the hospital, and he thinks stress after the tornado may be why. Hines was planning to bring her a few Hershey’s Kisses, her favorite candy, to lift her spirits.

Shannette BoClair, 52, said she found her infirm father, Albert Noble, on the floor in the fetal position after the tornado passed her parents’ home. A window had imploded and strong winds knocked him down. BoClair called 911 but, she said, first responders were overwhelmed by calls for help and tree-blocked streets. Her father needed medical attention right away, she said, so his family helped him hobble a mile to his grandson, who drove him to a triage station that had been set up for tornado victims.

They learned he had broken his hip, she said. He had surgery within days.

BoClair, who works as a health and wellness director at the YMCA, said she’s helping care for her mother, who remained at home after the storm. BoClair is depending on meals provided by volunteers and staffers at the YMCA but said she had also spent about $500 on DoorDash meals to feed her family since the tornado hit.

As far as federal aid goes, BoClair said she hopes it comes soon. The community needs dumpsters for the debris, reconstruction, and more.

But the outpouring of support from volunteers amazed her. The People’s Response drew so many volunteers that lines of cars snaked outside of the YMCA parking lot in North City. The smell of barbecue wafted through the air as residents without electricity grilled food for one another before it spoiled.

“I’m so proud of our community,” BoClair said. “They say we don’t care. We do care.”

Reed said volunteers would be stationed in the YMCA’s parking lot for a few more days. But, she said, that doesn’t mean the job ends there. The community will need more help to rebuild.

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

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The post Volunteers Help Tornado-Hit St. Louis Amid Wait for Federal Aid appeared first on kffhealthnews.org

Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This article primarily reports on the severe impacts of a tornado in St. Louis, highlighting the struggles of affected residents, especially in a predominantly Black neighborhood facing systemic challenges. It emphasizes community resilience and volunteer efforts while critically noting delays and uncertainty around federal disaster aid, referencing President Donald Trump’s prior denials of aid requests. The inclusion of social and racial disparities alongside scrutiny of governmental response suggests a perspective attentive to social justice and equity, aligning with Center-Left viewpoints. However, the piece maintains an overall factual and empathetic tone without overt partisanship.

CHARLESTON, S.C. — When Page Campbell’s doctor recommended she try an injectable prescription drug called Wegovy to lose weight before scheduling bariatric surgery, she readily agreed.

“I’ve struggled with my weight for so long,” said Campbell, 40, a single mother of two. “I’m not opposed to trying anything.”

In early April, about four weeks after she’d started taking Wegovy, Campbell said she hadn’t experienced any side effects, such as nausea or bowel irritation. But she doesn’t use a scale at home, she said, so she didn’t know whether she’d lost any weight since her most recent medical appointment earlier this year, when she weighed 314 pounds. Still, she was confident about achieving weight loss.

“It’s going to work because I’m putting in the work. I’m changing my eating habits. I’m exercising,” said Campbell, a shipping manager at a Michaels store. “I’m not going to second-guess myself.”

Wegovy belongs to a pricey class of drugs called GLP-1s (short for glucagon-like peptide-1 agonists) that have upended the treatment of obesity in recent years, offering hope to patients who have tried and failed to lose weight in myriad other ways.

Campbell gained access to Wegovy through South Carolina Medicaid’s decision in late 2024 to cover these weight loss drugs. But the medications remain out of reach for millions of patients across the country who could benefit from them, because many public and private health insurers have deemed the drugs too expensive.

A report published in November by KFF, a health information nonprofit that includes KFF Health News, found only 13 states were covering GLP-1s for the treatment of obesity for Medicaid beneficiaries as of August. South Carolina became the 14th in November.

Liz Williams, one of the report’s authors and a senior policy manager for the Program on Medicaid and the Uninsured at KFF, said she was not aware of any other state Medicaid programs joining the list since then. Looking ahead, the remaining states may be reluctant to add a new, expensive drug benefit while they brace for potential federal cuts coming from Congress, she said.

“As the budget debate, federally, is developing, that may impact how states are thinking about this,” Williams said.

The federal government won’t be helping anytime soon, either. Medicare covers GLP-1s to treat diabetes and some other health conditions, including obstructive sleep apnea and cardiovascular disease, but not obesity. In early April, the Trump administration announced it will not finalize a rule proposed by the Biden administration that would have allowed an estimated 7.4 million people covered by Medicare and Medicaid to access GLP-1s for weight loss. Meanwhile, the FDA is poised to force less expensive, compounded versions of these drugs off the market.

And the barrier to entry remains high, even for Medicaid patients in those few states that have agreed to cover the drugs without a federal mandate.

Case in point: In South Carolina, where more than one-third of all adults, and nearly half of the African American population, qualify as obese, the state Medicaid agency estimates only 1,300 beneficiaries will meet the stringent prerequisites for GLP-1 coverage.

Under one of those requirements, Medicaid beneficiaries who wish to access these drugs to lose weight must attest to “increased exercise activity,” said Jeff Leieritz, a spokesperson for the South Carolina Department of Health and Human Services.

Campbell, who is insured by Medicaid, was granted coverage for Wegovy based on her body mass index. First, though, she was required to submit six months’ worth of documentation proving that she’d tried and failed to lose weight after receiving nutrition counseling and going on a 1,200-calorie-a day diet, said Kenneth Mitchell, one of Campbell’s doctors and the medical director for bariatric surgery and obesity medicine at Roper St. Francis Healthcare.

Campbell’s Wegovy prescription was approved for six months, Mitchell said. When that authorization expires, Campbell and her health care team will need to submit more documentation, including proof that she has lost at least 5% of her body weight and has kept up with nutrition counseling.

“It’s not just, ‘Send a prescription in and they cover it.’ It’s rather arduous,” Mitchell said. “Not a lot of folks are going to do this.”

Mitchell said South Carolina Medicaid’s decision to cover these drugs was met with excitement among those working in his medical specialty. But he wasn’t surprised that the state anticipates relatively few people will access this benefit annually, since the approval process is so rigorous and the cost high. “The problem is the medicines are so expensive,” Mitchell said.

Novo Nordisk, which manufactures Wegovy, announced in March that it was cutting the monthly price for the drug from $650 to $499 for cash-paying customers. The price that health insurance plans and beneficiaries pay for these drugs varies, but some GLP-1s cost more than $1,000 per patient per month, Mitchell said, and many people will need to take them for the rest of their lives to maintain weight loss.

“That is a tremendous price tag that someone has to foot the bill for,” Mitchell said.

That’s the reason California Gov. Gavin Newsom on May 14 proposed eliminating Medicaid coverage of GLP-1s for weight loss starting Jan. 1, to save an estimated $680 million a year by 2028.

And the North Carolina State Health Plan Board of Trustees voted last year to end coverage of GLP-1s for state employees, after then-North Carolina Treasurer Dale Folwell’s office estimated in 2023 that the drugs were projected to cost the State Health Plan $1 billion over the next six years. The decision came only a few months after a separate North Carolina agency announced it would start covering these drugs for Medicaid beneficiaries. North Carolina Medicaid has estimated it will spend $16 million a year on GLP-1s.

South Carolina Medicaid, which insures fewer than half the number of people enrolled in North Carolina Medicaid, anticipates spending less. Leieritz estimated GLP-1s and nutrition counseling offered to Medicaid beneficiaries in South Carolina will cost $10 million a year. State funding will cover $3.3 million of the expense; the remainder will be paid for by matching Medicaid funds from the federal government.

In a recent interview, Health and Human Services Secretary Robert F. Kennedy Jr. didn’t rule out the possibility that Medicare and Medicaid might cover GLP-1s for obesity treatment in the future as costs come down.

They’re “extraordinary drugs” and “we’re going to reduce the cost,” Kennedy told CBS News in early April. He said he would like GLP-1s to eventually be made available to Medicare and Medicaid patients who are seeking obesity treatment after they have tried other ways to lose weight. “That is the framework that we’re now debating.”

Meanwhile, public health experts have applauded South Carolina Medicaid’s decision to cover GLP-1s. Yet the new benefit won’t help the vast majority of the 1.5 million adults in South Carolina who are classified as obese, according to data published by the South Carolina Department of Public Health.

“We still have some work to do,” acknowledged Brannon Traxler, the public health department’s chief medical officer.

But the state’s new “Action Plan for Healthy Eating and Active Living,” written by a coalition of groups in South Carolina, including the Department of Public Health, makes no mention of GLP-1s or the role they might play in lowering obesity rates in the state.

The action plan, underwritten by a $1.5 million federal grant, isn’t meant to lay out an overarching approach for lowering obesity in South Carolina, Traxler said. Instead, it promotes physical activity in schools, nutrition, and the expansion of outdoor walking trails, among other strategies. A more comprehensive obesity plan might address the benefits of surgical intervention and GLP-1s, but those also carry risk, expense, and side effects, Traxler said.

“Certainly, I think, there is a need to bring it all together,” she said.

Campbell, for one, is taking the comprehensive approach. On top of injecting Wegovy once weekly, she said, she is prioritizing protein intake and moving her body. She also underwent weight loss surgery in late April.

“Weight loss is my biggest goal,” said Campbell, who expressed appreciation for Medicaid’s coverage of Wegovy. “It’s one more thing that’s going to help me get to my goal.”

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

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The post Trump Won’t Force Medicaid to Cover GLP-1s for Obesity. A Few States Are Doing It Anyway. appeared first on kffhealthnews.org

Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This article presents a generally factual and empathetic perspective on access to weight loss drugs through Medicaid, highlighting the challenges and policy decisions affecting coverage. It critiques cost barriers and political decisions from the Trump administration and some state governments, which aligns with a viewpoint that supports increased healthcare access and government intervention in health coverage. The tone is balanced but leans slightly left by emphasizing the importance of public health and expanded coverage via Medicaid while pointing out the budget cuts and coverage restrictions primarily associated with conservative or right-wing policy positions.