The cost for hospital services is covered under many insurance plans.
Costs that are covered include charges for services such as physician care,
laboratory tests, x-rays, medical treatments, surgery and routine nursing
care. It is important to understand the various programs that pay for hospital
services.
MEDICARE
Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant).
Medicare consists of two parts:
MEDICARE PART A covers institutional care in hospitals and skilled nursing facilities, home health care and hospice care. Eligible individuals pay no premium for the Medicare Part A program.
MEDICARE PART B covers “outpatient” care. This includes office visits to medical specialists, limited ambulance transportation, diagnostic tests performed on an outpatient basis, physician visits while the patient is in the hospital, durable medical equipment such as wheelchairs, and various outpatient therapies that are prescribed by a physician. Part B enrollees pay a monthly premium that is adjusted annually. Usually Medicare Part B pays 80% of the approved fee for the services rendered. The remaining 20% of the fee (called a co-pay) is the patient's responsibility. If your loved one has a Medigap (PDF) policy, it will pay this co-pay amount.
Medicare beneficiaries may also receive their medical care from a number
of Medicare Advantage Plans (Medicare Part C). Medicare Advantage Plans are managed by private insurance
companies approved by Medicare. The plan covers all the benefits of Medicare but may charge co-payments,
offer extra services and may also limit the physicians and hospitals the person may utilize.
it the physicians and hospitals the person may utilize.
Medicare Coverage In Hospitals
Medicare will pay for virtually all hospital charges the first 60
days, except for a deductible. This deductible is the patient's
responsibility, if it is not covered by a Medigap policy.
| Medicare does not pay for treatments or procedures that it considers medically unproven or experimental. |
Hospital services covered by Medicare:
A bed in a semiprivate room
All meals
Regular nursing services
Operating room, intensive care unit, coronary care unit charges
Medical supplies
Medications furnished by the hospital
Laboratory tests
X-rays
Use of appliances
Medical social services
Physical therapy
Occupational therapy
Speech therapy
Blood transfusions, after the first three pints
Medicare will help pay for a second opinion before surgery. If your surgery is not an emergency, that is, it does not need to be done right away, talk with your doctor and decide what is best for you. You may decide that it is best for you to get a second opinion from another doctor. Medicare will also help pay for a third opinion if the first and second opinions are different.
Medical Assistance is a federal and state program that provides health
insurance for individuals with low income and/or special health needs.
Medical
Assistance covers inpatient hospitalization and outpatient
services. To be eligible for Medical Assistance, an individual must meet
medical
and financial requirements.
If a patient becomes eligible for Medical Assistance benefits while hospitalized,
the social worker may provide guidance through the application process.
| Eligibility for Medical Assistance varies by state. If your loved one lives outside of Maryland, check that state's eligibility requirements. The Centers for Medicare and Medicaid Services has information about each state's eligibility requirements. |
Application Process
In Maryland, the local Department of Social Services processes all applications for the Maryland Medical Assistance Program. The Department of Social Services in Baltimore County has five offices to serve you. Call or visit an office to obtain an application.
DEPARTMENT OF VETERANS AFFAIRS
The Department of Veterans Affairs operates hospitals across the country. The Department of Veterans Affairs determines eligibility for all services, whether inpatient or outpatient.
PRIVATE INSURANCE
Many companies provide private health insurance. All cover inpatient
services, but there may be a limit to the number of days covered or to
the total cost paid. Co-payments and deductibles vary with each insurance
policy. The Maryland
Insurance Administration provides information about health
insurance companies operating in the state and explains how to file
complaints against companies, should you have problems with
payment.
| It is important to read your health insurance policy to determine if you need pre-authorization for non-emergency admissions and procedures. Also, look to see if services will only be covered at specific hospitals. |
If your loved one has insurance that does not cover the full cost of
hospital care, or has no insurance at all, he or she will be billed for
the non-covered amounts. If he or she cannot afford to pay the billed
amounts, it is important that you make contact with the hospital financial
office as soon as possible to discuss payment options. The staff there
can advise you about other payment methods (such as time payments), or
sources of financial aid, such as Medical Assistance or the Hill-Burton
program. Hill-Burton hospitals provide free, or below cost, health care
to people unable to pay. Eligibility for these programs is based on family
size and income. For information about the Hill-Burton program,
call the hotline at 1-800-638-0742; Maryland residents can call 1-800-492-0359.
| In emergency situations, all hospitals in Maryland must treat a person experiencing a medical emergency regardless of their ability to pay |
LENGTH OF STAY
Regardless of the insurer, the patient's length of stay in the hospital is based on the patient's need for acute care services (inpatient hospital services) as determined by the physician. The doctor documents the patient's ongoing needs in the medical chart. A review agency monitors the medical charts to make sure individuals only remain in the hospital if there is a medical need. If the review agency determines that the patient is medically able to leave the acute care hospital, and the physician and/or family disagree with this decision, an appeal can be initiated. There may be an occasion when a patient wants to remain in the hospital to recuperate a little longer and the doctor states that there is no medical need to prolong the stay. In that case, the review agency will not authorize a continued stay.