Every employer’s benefit plan design is different. Some categories of services may be covered under one plan, but not covered under another plan. Please review your plan closely before receiving scheduled services to make sure that the service is a covered benefit under your plan.
Services that may not be covered include:
- Non-emergent service provided in an emergency room setting
- Family planning services
- Services deemed to be cosmetic in nature
- Services not considered medically necessary
To determine whether a service is covered, please contact your insurance company to inquire about benefit levels for planned services. If you receive a service that is not covered under your benefit plan, the balance will be your responsibility and will be billed to you directly. If a service is deemed not to be covered by insurance, you may be eligible for a discount. For information on discounts for your hospital bill, please contact WVU Hospitals Patient Financial Services at 800-516-5548. For information on discounts for your physician’s bill, please contact University Health Associates Patient Financial Services at 304-285-7100 or 800-541-4009.
Acute Inpatient vs. Outpatient Services
Your illness, condition, or medically necessary service may not require inpatient hospitalization. However, your physician may request that you be assigned to a hospital room for a period of monitoring until there can be a more definite determination of your healthcare needs. At intervals during your stay, your attending physician and our care management team will evaluate whether you will require admission to the hospital as an inpatient. If you are not admitted and you have insurance, the hospital will file a claim for outpatient services and your insurance will apply outpatient benefit levels when processing the claim, including any deductible or coinsurance that may apply. If you have Medicare, you will also be responsible for any drugs that Medicare considers self-administered. You may bring any prescription medications with you to avoid these added costs.
If you have Medicare and would like more detail, please review CMS publication 11435.
Your Portion of Your Healthcare Expense
You pay for your health insurance in two ways: premiums and out-of-pocket expenses. Your premium is a monthly amount to purchase your health insurance plan.
You also may have the following out-of-pocket expenses that will be required when you receive healthcare services. There are a few different kinds of out-of-pocket expenses. Your plan may have all or none of these.
- Deductible: The amount you have to pay every year before your health insurance begins paying for its share of your services. Like your auto or homeowners insurance, this is a fixed amount (for example, $1,000, $5,000, or $10,000). Some plans reach the deductible based on each individual’s expenses, and some are based on the expenses of the whole family. Some services, like preventative care, may be excluded from the deductible depending on your plan.
- Copayment (Copay): A fixed expense for each visit of a certain type of care. The most common would be a doctor’s office visit (e.g. $25) or for emergency room care (e.g. $100).
- Coinsurance: The percentage of your medical cost that you are responsible for paying. If you have an 80/20 plan, your insurance will pay 80 percent of the bill, while you are responsible for 20 percent.
- Out-of-Pocket Maximum: This is the most of your healthcare cost that you will be expected to pay in a single plan year. Once you have paid the out-of-pocket maximum, the insurance plan will no longer apply coinsurance to your bills and will pay 100 percent of the allowed expenses.
Example (for illustrative purposes only)
It is the beginning of your plan year. Your plan has a $1,000 deductible, 20 percent coinsurance, and a $2,000 annual out-of-pocket maximum. You are admitted to the hospital and incur a bill of $50,000.
If you have questions about your healthcare benefits, please contact your insurance company directly, contact a financial counselor at 304-598-6260, or call our WVU Hospitals Patient Financial Services office at 800-516-5548.