9. 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.
Planned Hospitalizations
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 follow-up 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?
[Return
to FAQ]
|
