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Hospital stays: How to understand your health insurance hospital coverage

health insurance hospital coverage

In 2010, there were 35.1 million hospital discharges in the United States. About 7.6 percent of Americans had an overnight stay, with the average length being about five days.

A hospital stay can be unexpected and expensive and navigating a hospital stay can be scary and confusing.

The good news is that the Affordable Care Act includes hospitalization as one of the 10 essential health benefits.

Find out how a health insurance plan covers hospital visits, the role of hospitalists (doctors who specialize in the care of hospital patients) and tips for navigating hospitals.

Hospital insurance coverage and bills

How much hospital coverage your plan provides varies depending on your specific plan. In your policy, look for terms for like “inpatient hospital services”, “hospital care”, or “hospitalization”. 

In some plans, hospital coverage is listed by the type of medical situation, such as maternity care.

For example, if you have an Obamacare "bronze plan" 60 percent of hospital costs will be covered and your copay will be40 percent.

For example, if your bill is $3,000, insurance would pay $1,800 and you would pay $1,200.

"Hospital bills can be very confusing. The itemized list isn't usually what patients owe -- it's just a summary of all expenses. Most patients only pay a portion of those costs after their health insurance coverage has been applied," says John Combes, senior vice president of the American Hospital Association (AHA), a national organization that represents health care providers and patients.

Some insurance plans only pay a portion of what the hospital charges for costs or have a deductible.

Say you have a $1,000 deductible: During your plan year, you’ll pay 100 percent of the costs for most services until you hit the $1,000 mark, which is when your insurance coverage will kick in.  

The hospital care team

While in the hospital, you may see doctors, nurses, medical assistants and hospitalists.

  • Doctors that you may see in the hospital include pediatricians, internists, surgeons, and emergency medicine doctors.
  • Nurses administer medication, provide health education, and monitor vital signs like blood pressure.
  • Medical assistants help doctors and nurses by taking medical histories, drawing blood, and preparing patients to be examined.
  • A hospitalist is always in the hospital and coordinates your medical care during your stay. Additionally, your hospitalist will stay in contact with your primary care doctor to make sure you get the best possible care while in the hospital and after you leave.

"One of the most important things that we do is to manage the patient's transition from the hospital back to the community where they will continue their care," says Brad Flansbaum, a practicing hospitalist in New York City.

For example, a hospitalist will inform relevant parties (such as your primary care physician) if there's a specific plan for treatment that should be followed after you’ve been discharged.

Hospitalists are more common in big cities and large health care systems. In smaller areas, some primary care physicians in the community still manage their patients while they're in the hospital.

4 tips for navigating your hospital stay

Here are 4 tips to help you understand what’s going on and how to ask for what you need during your hospital stay.

1. Review your insurance plan.

Be familiar with your insurance policy. If you’re having a prescheduled procedure or life event that you can plan for like hip surgery or having a baby, call your insurance provider to ask what’s covered and if you’ll have a co-pay.

2. Ask questions.

Write down all of your questions and concerns. Don't be afraid to talk about them with the hospital team.

3. Bring a loved one or friend.

Being in the hospital can be overwhelming. It helps to have someone take notes for you and to be your advocate when you're not feeling well.

4. Make sure you know the treatment plan and follow-up details.

It's important you and your loved ones know what will happen once you leave the hospital. This includes understanding your medications, when to see your primary care doctor for a follow-up visit, and who to call if you have complications.

How to find a hospital -- and make sure your insurance covers it

There are many websites and lists that compare statistics about hospitals. For example, Hospital Compare, an official Medicare website, allows you to search hospitals by ZIP code.

In addition to being able to compare multiple hospitals, you can find information about the number of complications related to heart attacks, heart failure, pneumonia, surgery and other conditions.

If you're getting a prescheduled surgery or treatment for a condition such as cancer, your primary care physician may also be able to recommend a hospital. Check with your insurance provider regarding which hospital and health care providers are covered under your plan.


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