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 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?
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