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Medical Claims, Insurance, Medicare and Medicaid

Finances

Sometimes the scariest part of health care is the financial impact. Health care is expensive, and negotiating the financial maze of health care can be daunting. There’s insurance, deductibles, co-pays, Medicare and Medicaid, which many people confuse or misunderstand. Medicare A, Medicare B, and now Medicare D. 

Especially Medicare Part D. The newest Medicare plan addresses prescription drug coverage, and selecting a Part D plan can be confusing for Medicare beneficiaries. Below is a list of tips from Jim Loveless, Director of Medicare for SummaCare.

1. The recent changes in Medicare affect all Medicare beneficiaries. There has been some confusion around who this affects, but all Medicare beneficiaries need to be aware that it affects them and they have a choice to make.
2. Don’t just sign up for any plan. There are a lot of option out there for Medicare-eligibles to consider. Consider the premium, the list of drugs available on the plan, co-pays and coverage within the “gap.”
3. Consider Medicare Advantage Plans. Some Medicare Advantage plans provide the Part D benefit at $0 premium.

Patients Who Have Health Insurance

If you have health insurance, we will need a copy of your insurance identification card. We also may need copies of your insurance forms, which are supplied by your employer or your insurance company. You will be asked to assign benefits from the insurance company directly to your hospital. You should familiarize yourself with the terms of your insurance coverage so that you will understand the hospital’s billing proceduresm charges and any potential out-of-pocket expenses you may incur.

Pre-Certification

If you have health insurance, it is your responsibility to determine whether your insurance coverage requires pre-certification. If you are uncertain about pre-certification, please contact your employer or health insurer. Pre-certification authorization should be obtained prior to your hospital admission. If you admission was an emergency, many insurers may allow you 24 to 48 hours to obtain your pre-certification authorization. Please consult your insurer for details.

Patients Who Belong to an HMO or PPO

Your HMO or PPO plan may have special requirements, such as a second surgical opinion or pre-certification for certain tests or procedures. It is your responsibility to ensure that the requirements of your plan have been satisfied. If your plan’s requirements are not met, you may be financially responsible for all or part of the services rendered in the hospital. Please note that some physician specialists may not participate in your health care plan and their services may not be covered.

Patients Who Are Covered by Medicare

If you are covered by Medicare, we will need a copy of your Medicare card to verify your eligibility and to process your Medicare claim. Medicare plans specifically exclude payment for certain items and services, such as cosmetic surgery, some oral surgery procedures, personal comfort items, hearing evaluations and others. Deductibles and co-payments also are the responsibility of the patient. Unless you had previous knowledge that the care you received was unnecessary, you will not have to pay any unapproved amount. If you have any questions, please call the health care review department at 330-375-3888.

Patients Who Are Covered by Medicaid

If you are covered by Medicaid, we will need a copy of your Medicaid care. Medicaid has payment limitations on a number of services and items. Medicaid does not pay for the cost of a private room unless it has been determined that a private room is a medical necessity.

Uninsured Patients

If you do not have a health insurance plan, a financial counselor will discuss financial arrangements with you. A hospital representative is available to assist you in applying for Medicaid or other government assistance programs. If you have any questions, please call the patient access department at (330) 375-3215.

Your Hospital Bill

Your hospital is responsible for submitting bills to your insurance company and will do everything possible to expedite your claim. Please remember that your health insurance policy is a contract between you and your insurance company and you have the final responsibility for the payment of your hospital bill. Summa Health System offers various assistance programs for individuals who need help paying their hospital bills. Applications for these programs may be obtained by contacting Summa Patient Account Services at 330- 996-8505 or 1-800-543-7750 (in Ohio); or Medicare patient accounts at 330-996-8499 or 1-800-543-7750 (in Ohio).

Your hospital bill reflects all of the services you received during your stay. Charges fall into two categories: a basic daily ratem which includes your room, meals, nursing care, housekeeping and telephone; and charges for special services, which include items your physician orders for you, such as X-rays or laboratory tests.

If you have certain tests or treatments while you are in the hospital, you may receive bills from physicians you did not see in person. These bills are for professional services rendered by these doctors in diagnosing and interpreting test results while you were a patient. Pathologists, radiologists, cardiologists, anesthesiologists and other specialists perform these services and are required to submit separate bills. If you have any questions about these bills, please call the number printed on the statement you receive.

Back to Summa Caregiver’s Kit page

 Source: Summahealth.org
 

More online resources to guide you with insurance, Medicare and Medicaid

Learn more about your rights with Medicare  
 
Medicare Fact Sheets  
 
Medicare Web Site  
 
Ohio Medicaid facts sheets  
 
The Ohio Department of Insurance