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Coverage and Cost

The type of health insurance you have plays an important part in your hospital choice. It determines which hospitals you have to choose from, and how much of your care will be covered. If you have no health insurance, the costs of your care, and how much assistance a hospital offers to help you pay for it, may affect where you choose to get care.

Private Insurance. Many people have health insurance with a health maintenance organization (HMO) or preferred provider organization (PPO). These health plans limit the hospitals you can use for non-emergency care. Some plans will not pay for care at an "out-of-network" hospital, meaning one that doesn’t have a contract with the plan. Other plans use hospital "tiers." Depending on which tier a particular hospital is in, the plan pays all or a portion of your bills from that hospital. Also, you may be required to pay deductibles and/or co-payments for your hospital stay, which come directly out of your own pocket.

To find out if your plan covers a particular hospital, contact your plan directly, or speak with your employer's plan administrator (if you are enrolled in the plan through your work). Most plans also provide this information on their Web sites.

Medicare Advantage Plans. In California, some Medicare beneficiaries are enrolled in special Medicare HMOs or other managed care plans known as Medicare Advantage. In terms of hospital choice, these plans have the same kinds of limits as the private insurance plans discussed above.

Switching Plans. If your private insurance or Medicare Advantage plan does not completely cover care at the hospital that you prefer, you may be able to switch to another plan that covers that hospital. Many plans admit new members during an open enrollment period each year – usually between November 15 and December 31, though some plans have shorter or longer enrollment periods. You may be able to enroll in another plan, or in a different plan within the same insurance company that offers coverage at your hospital of choice. Switching plans to get coverage at a particular hospital is only possible if the care you need isn't immediate, such as with childbirth or a surgery or other procedures that do not need to be performed right away.

Kaiser Permanente. Many Californians have health coverage through Kaiser, which owns and operates its own hospitals. If you are enrolled in Kaiser, you must receive care at one of Kaiser's hospitals, except when no Kaiser hospital in your area performs the procedure you need.

Medicare Fee-for-Service. Most Medicare beneficiaries in California receive their Medicare Part A (hospital insurance) coverage directly through the Medicare program rather than through managed care plans. Since almost every licensed hospital in California is also Medicare-approved, if you have this traditional "fee-for-service" Medicare coverage, you can choose any hospital you prefer.

Be aware, however, that Medicare may not pay the full amount of your hospital bill. There is a yearly deductible ($992 in 2007), plus daily co-insurance amounts if you are hospitalized for more than 60 days in a row. Visit the Medicare Web site for an explanation of the amounts it does and does not pay for a hospital stay.

Medi-Cal. Because not all California hospitals participate in the Medi-Cal program, your Medi-Cal coverage might not be accepted at the hospital that you prefer. At the very beginning of discussions with your doctors about your need to enter the hospital, you should remind the doctors that any hospital they recommend must accept Medi-Cal patients. For more information on Medi-Cal coverage, visit the Medi-Cal Web site.

Uninsured. More than 6.5 million Californians don't have health insurance. If you are one of these uninsured, you must think about how you will pay for your hospital stay. When considering different hospitals, you must find out from each hospital:

• The daily rate for the particular level of care you will be receiving. This rate may change during your stay, depending on the level of care you receive. You must ask your doctors and the hospital administrator to explain the levels of care you are likely to receive for your condition or treatment.
• The hospital's charges for the treatment or procedure you expect to undergo. These are the hospital's own charges for these treatments or procedures. The doctors who administer or oversee them will also charge you separately.

For help comparing hospital charges, see the California HealthCare Foundation report, "Price Check: The Mystery of Hospital Pricing." When it comes time to decipher a hospital bill, and to make sure the charges are accurate, advice is available from the nonprofit consumer advocacy group, Consumers Union.

Help paying your hospital bill may also be available. Some hospitals have their own programs in place, or can put you in contact with outside programs that can help you pay the bills. These programs may significantly lower the total amount of your hospital bill. Also, some hospitals offer payment plans, which can stretch out payment of hospital bills over time at lower-than-market interest rates.