Hospitalization Explained

Each plan covers hospital stays a little differently so be sure to read through your benefits carefully. Most plans require you to pay a share, or percentage, of the cost of your hospital care. This is called coinsurance, and it usually doesn’t apply until after you’ve met your deductible. Other plans may require you to make a copayment (i.e., pay a set dollar amount) for a hospital stay, either instead of or in addition to paying coinsurance and meeting your deductible.

No matter how your plan handles cost-sharing, the way you’re billed for hospital stays is often the same: confusing! It’s unlikely you’ll get just a single bill for all the services you’ve received. In most cases, you’ll get separate bills for each type of care. Some of those could include:

• A facility fee — that’s insurance-speak for hospital room charges.
• Your primary care physician’s services.
• Any specialists’ care you receive, including from an anesthesiologist. And services that might surprise you: For example, if your doctor calls in a specialist to consult, you’ll receive a separate bill from that specialist.
• Medications
• Lab tests and other diagnostics

The amount your insurance will pick up for each of these bills depends on your particular plan.

If possible, choose a hospital that’s part of your plan’s network. And also check to see if the other service providers are in-network too. Just because your hospital is on your insurance carrier’s in-network list doesn’t mean all the providers who take care of you will be. For example, your surgeon might be in-network (and would charge you a copay), but maybe the anesthesiologist he or she prefers to work with is not. In that case, you could end up paying the full cost for their services.

Don’t be afraid to ask questions about who’s providing your care, and whether they’re in your network. Also, be sure to check with your insurance company if you’re unclear about what’s covered and what isn’t. Speak up if you don’t understand something.

In the event of an emergency, don’t worry about whether the nearest hospital is in-network. If you think you’re having a heart attack, or your spouse is having trouble breathing, or your child fell off a scooter and fractured his arm, you can (and should) go to the nearest emergency room. All new health plans must cover emergency treatment in these types of situations, even if you go to an emergency department that’s out of network. You won’t be charged higher copays or coinsurance than you’d pay for in-network emergency room care. This even applies to HMO and EPO plans, which typically don’t cover out-of-network care at all.

(However, it’s worth a heads-up here about a practice called balance billing. That’s when you receive bills for the unpaid balance of charges that are above and beyond what your insurance company covers.)

If you receive emergency care in an out-of-network hospital, you may not be covered for additional hospital care beyond the emergency room. If you require inpatient treatment, you may need to be transferred to an in-network hospital or ask your insurance company to cover your hospital stay.

What else you need to know

Not all hospital visits are overnight. If you go the hospital for a procedure such as a cataract removal, a test, or an MRI scan, you may be in and out in just a few hours. That’s called an outpatient visit. Your copays may be different — and significantly lower — than for inpatient stays, depending on your plan.

If you know there’s an inpatient hospital stay in your suture, do your homework. If you live in an area where you have more than one hospital to choose from, you may save a bundle by shopping around and comparing facility, doctor, and other fees.