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It's not just uninsured patients who rack up steep medical bills. Even if you have insurance, you might not realize that your coverage is inadequate until you're sick and overwhelmed by co-payments and other health costs.

"Medical costs are the single largest contributor to people declaring bankruptcy," often including those who already have insurance, said Ron Pollack, executive director of Families USA, an advocacy group.

To help consumers avoid getting buried under hospital bills, Families USA recently published a handbook, "Your Medical Bills: A Consumers Guide to Coping with Medical Debt," which is available online at Along with that, the group published a list of what Maryland and some other states have done lately to protect residents from medical debt.

Maryland added protections starting in June after a series of articles last year in The Baltimore Sun that showed aggressive collection tactics used by some hospitals against low-income residents, even though their unpaid bills are covered through rates charged to all patients. The law now requires hospitals here to provide free or reduced-price care to low-income residents and to give patients information about financial assistance.

This protection may be expanded soon to make even more Marylanders eligible for free or reduced-cost care.

So what do you do if you face big medical bills?

The first step is to make sure the hospital bill is correct, Pollack said during a recent news conference announcing the consumer guide. Sometimes you may be billed twice for services that you received only once or not at all, he said.

Request an itemized copy of your bill. Also, check your medical record to make sure the services on the bill were actually provided to you, he said.

If your insurer refuses to pay a claim, you can file an appeal with the company to review its initial decision, Pollack said. If that doesn't work, some states allow you to file an appeal with them. Marylanders whose insurer won't pay for treatment considered a medical necessity can file an appeal with the Maryland Insurance Administration.

Low-income patients should check to see whether they are eligible for Medicaid. "If you are, you should only be paying for very minor copayments," Pollack says.

Marylanders with limited means have additional options.

Maryland hospitals now must provide free care to residents whose income falls below 150 percent of the federal poverty level - or $27,465 for a family of three, said Stephen Ports, principal deputy director for the Health Services Cost Review Commission, which sets rates for hospital services. Hospitals also must offer a reduced price for other low-income residents, although it's up to the hospitals to determine who qualifies.

A work group within the Review Commission last month proposed an expansion of this protection.

In a proposal now undergoing public comment, free care would be provided to residents whose income fell below 200 percent of the federal poverty level, or $36,620 for a family of three, Ports said. And those who fall between 200 percent and 300 percent ($54,930 for a family of three), would get reduced-cost care. Hospitals facing financial hardship, though, could petition the commission for some leeway on this, he said.

Among other suggestions, the work group recommends legislation that would forgive certain medical debt incurred during the year that exceeds 25 percent of household income for low- to moderate-income patients. This provision would most likely help uninsured patients paying for medically necessary treatments, Ports said.

Of course, these changes are being discussed during a national debate on health care reform. But even if that passes, medical debt could still be a problem.

"Until we have health care for all, it will continue to happen," said Vincent DeMarco, president of Maryland Citizens' Health Initiative.

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