ICHRA Members and Medical Bills Who Helps When the Bill Arrives

With a group plan, an employee with a confusing bill can walk over to HR, and HR can call the plan. With an ICHRA, that path mostly isn't there. The employee chose their own plan, the insurer is theirs, and when the bill arrives they are often on their own with it.

How does an individual coverage HRA change who handles a medical bill?

It moves the whole insurance relationship to the employee. An individual coverage HRA reimburses medical expenses, like monthly premiums, and requires the employee and any covered family members to have individual health insurance or Medicare. They can get a plan through the Marketplace or directly from an insurance company. Short term plans and dental or vision only plans don't count.

The federal rule that created ICHRAs also keeps the employer at arm's length from that plan. The individual coverage isn't part of the employer's ERISA plan as long as a set of conditions are met. Two of them matter here: the employer doesn't select or endorse any particular insurer or coverage, and every participant is told each year that the individual coverage isn't subject to ERISA.

That's by design, and it's part of what makes an ICHRA work. It also means that when a claim is denied or a bill looks wrong, there is no employer plan behind the employee to escalate to.

Is a CHOICE arrangement the same as an ICHRA?

Yes. CMS now uses the name CHOICE arrangement for what was formerly known as the individual coverage health reimbursement arrangement, or ICHRA. Everything in this guide applies under either name. We use ICHRA here because it's still the name most employees and brokers know.

Who does what when an ICHRA member gets a bill?

Each party has a narrow job. This is the usual split:

The gap is easy to see. Nobody in that list is there to read the bill, compare it with the explanation of benefits and work it on the employee's behalf. That job lands on the employee.

What rights does an ICHRA member keep on a medical bill?

All of the usual ones. Being on an individual plan doesn't take anything away. The ones that come up most:

• Compare the bill with the explanation of benefits. For in network care, the provider's bill should match what the explanation of benefits says the member owes. If it doesn't, the first call is to the provider. If they match but the insurer looks wrong, the next step is an appeal.
• Appeal a denied claim. The member can file an internal appeal with their insurer within 180 days of a denial. If that fails, they can ask for an independent external review within four months, and the insurer has to accept the reviewer's decision. Our denial appeals page covers how this works as a benefit.
• Ask for the itemized bill. Patients have a right to their billing records under HIPAA, and a provider can't withhold them over an unpaid balance. The itemized bill is where duplicate charges and coding errors show up. More on that on our billing errors page.
• Use surprise billing protections. Plans that cover emergency care have to cover it without prior authorization, whether or not the hospital is in network, at in network cost sharing. Ground ambulances are the big exception: they generally sit outside the federal protections unless state law says otherwise.
• Apply for hospital financial assistance. Every nonprofit hospital must have a written financial assistance policy, and eligibility depends on that policy. A patient who qualifies can't be charged more than the amounts generally billed to insured patients for emergency or medically necessary care, and has 240 days to apply. See our financial assistance page.

Does an ICHRA reimburse medical bills, not just premiums?

Sometimes. The federal rule gives the employer discretion over which medical care expenses the ICHRA reimburses. The rule expects most ICHRAs to reimburse premiums, and lets them cover other medical care expenses too. So it depends entirely on the ICHRA's terms.

Where the ICHRA does reimburse bills, it's worth checking a bill before it's paid. Once a wrong charge is paid and reimbursed, getting it corrected is harder for everyone. The same goes for HSA and FSA money, which we cover in our guide to paying old bills from an HSA or FSA.

What can the employer or ICHRA platform do?

Quite a lot, without ever touching the insurer relationship or an employee's health information:

• Put a short "when you get a bill" section into the ICHRA notice and the welcome materials. Employers generally have to send the notice at least 90 days before the ICHRA plan year starts, so it's a natural place for it.
• Explain the split in the table above, so employees know the insurer handles claims and the administrator handles reimbursement.
• Tell employees about appeal deadlines and financial assistance before they need them, not after a bill has gone to collections.
• Give them somewhere to send the bill itself. That's the piece nobody in the chain owns today.

If you are in HR and an employee has already come to you, our piece on what to do when an employee asks HR for help with a bill walks through that first conversation.

Where does outside help fit for ICHRA members?

In the gap between the insurer and the billing office. That is the part mediloop does. An ICHRA member sends their bill to mediloop directly. AI-powered investigation reads it and checks every charge against the explanation of benefits, and a human advocate, who is on every case, works the appeal, the error or the financial assistance application with the provider or insurer.

The employer or platform gets aggregate reporting only, and individual bills aren't routinely shared with it. It also doesn't change which insurer anyone picks. mediloop isn't neutral here, so read our explainer on medical bill advocacy benefits for how the category works in general. For ICHRA platforms specifically, the details are on our platforms page, and how we handle data is on our security page.