What if I Have to Go to the Hospital?
The time to find out what rules your plan has on hospital care is before you need it.
Unless it is a medical emergency, your health plan or primary care doctor will probably have to give advance approval (preadmission certification) for you to go to the hospital. Otherwise, the cost of your hospital care may not be covered. Ask these questions:
- What hospitals are part of the plan network?
- Is there a limit on how long I can stay in the hospital?
- Who decides when I am to be discharged?
- Will needed followup care, such as nursing home or home health care, be covered by the plan?
- If I have a serious medical problem, will the plan provide someone to oversee care and make sure my needs are met?
Ask how your plan handles getting a second doctor’s opinion on whether surgery or another treatment is needed. Are second opinions encouraged or required? Who pays?
Emergency or Urgent Care
If you have a true medical emergency, you should go to the nearest hospital as fast as possible. It is important for you to know what kind of medical problems are defined as emergencies and how to arrange for ambulance service, if needed. Most plans must be told within a certain time after emergency admission to a hospital. If the hospital is not part of the plan network, you may be transferred to a network hospital when your condition is stable. Ask these questions:
- How does the plan define “emergency care?” What conditions or injuries are considered emergencies?
- How does the plan handle “urgent care” after normal business hours? Urgent care is for problems that are not true emergencies but still need quick medical attention. Check with your plan to find out what it considers to be urgent care. Examples may include sore throats with fever, ear infections, and serious sprains. Call your primary care doctor or the plan’s hotline for advice about what to do. The plan may also have urgent care centers for members.
- How do I get urgent care or hospital care if I am out of the area? How must I tell the plan and how soon after I get the care?
What if I Am Not Satisfied with My Care?
Getting the best care and services means understanding how your health plan works, what your rights are, and how to complain if you need to. You have the right to get copies of test results as well as medical information about yourself. If you are in a managed care plan, you can ask to change your primary care doctor if you are unhappy with the relationship. You may also be able to switch plans during open enrollment.
Most plans have an appeals process that both you and your doctor may use if you disagree with the plan’s decisions. If your plan refuses to provide or pay for services, you can complain or file a grievance about any decision you feel is unfair–or you can appeal it.
You can contact the member services division of your plan for more information or to complain. Use your plan’s complaint process fully before taking other action.
Be sure to keep written records of:
- All correspondence with the plan.
- Claims forms and copies of bills.
- Phone conversations–the date and time, the people you speak with, and the nature of each call.
If the plan does not satisfy you, you may decide to bring the matter to the attention of your employee benefits manager, your State insurance commissioner, your State department of health, or the legal system. If you are a Medicare or Medicaid beneficiary, you have additional ways through those programs to file a grievance about the care received from a plan or provider. For information, contact your State’s medical Peer Review Organization or State Medicaid Program.