ER->Observation->Inpatient on MA Plan?

[NYBernie]

Trying to understand the billing/charges on a Medicare Advantage plan. Does anyone have an example (or cheat sheet) for how the charges would stack-up for the following scenario:

Client goes to ER for abdominal pain (spends 4hrs in ER), in observation status for 28hrs (moved from ER to hospital room; tests; doctor visits; etc), then admitted for two days.

Here are some examples from a local MA plans EOC:

Outpatient Hospital Services:
- $65 copay for each emergency service (waived if admitted within 23hrs)
- 20% coinsurance for each outpatient hospital and observation service
- $15 PCP copay and $50 Specialist copay for labs and each diagnostic test
- $50 copay for each x-ray, 20% for radiation therapy, 20% for each advanced radiology diagnostic service (CT scans, PET scans, and MRI/MRA)

Inpatient Hospital Care:
- Days 1-5 = $325/day

Do they get hit with the ER copay (for each emergency service?), then outpatient copays/coinsurance for the next 28hrs, then $325/day once admitted?

I know, I'm trying to understand too much...just sell a Med Supp

 

[yaknow1]

No. Have you looked at a Summary of Benefits? Search for a plan on Humana's site. It is pretty simple to understand.

 

[NYBernie]

No. Have you looked at a Summary of Benefits?Search for a plan on Humana's site. It is pretty simple to understand.

Thanks for the response. I have looked at the SOB and the EOC - actually pulled the coverage numbers from the EOC of a local MA plan. I don't see where they explain how a single visit to the hospital, that spans emergency services, outpatient services (observation), and inpatient services, is covered or billed.

I can find this information for original Medicare, and it clearly states that the outpatient portion of your stay is covered under Part B, while the inpatient stay is covered under Part A - all within this one hospital stay.

 

[yaknow1]

Did the below sections not make it explicit?


Emergency Care $65 copay
If you are admitted to the hospital within 24 hours, you do not have to
pay your share of the cost for emergency care. See the "Inpatient
Hospital Care" section of this booklet for other costs.

INPATIENT CARE
Inpatient Hospital Care1 Our plan covers an unlimited number of days for an inpatient hospital
stay.
• $225 copay per day for days 1 through 7
• You pay nothing per day for days 8 through 90
• You pay nothing per day for days 91 and beyond