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.
In emergency situations, all hospitals in Maryland must treat a person experiencing a medical emergency regardless of their ability to pay.
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 Part B: covers “out-patient” care. This includes office visits to medical specialists, limited ambulance transportation, diagnostic tests performed on an out-patient basis, physician visits while the patient is in the hospital, durable medical equipment such as wheelchairs, and various out-patient therapies that are prescribed by a physician. Part B enrollees pay a monthly premium that is adjusted annually. Usually Medicare Part B pays 80 percent of the approved fee for the services rendered. The remaining 20 percent 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 Part C: 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 are considered medically unproven or experimental.
Medicare covers the following:
- Hospital services covered by Medicare:
- A bed in a semi-private room
- All meals
- Regular nursing services
- Operating room, intensive care unit, coronary care unit charges
- Medical supplies
- Medications furnished by the hospital
- Laboratory tests
- 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 in-patient hospitalization and out-patient 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.
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.
Other Insurance Plans
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.
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 in-patient or out-patient.
Many companies provide private health insurance. All cover in-patient 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.
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.
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.
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 (in-patient 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 disagrees 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.