Essential #3 – Hospitalization Insurance Benefits

Hospital signAha! This is one of those benefits that we expect all major medical insurance policies to cover – at least to some extent. And it is the third of the 10 essential benefits listed in the Affordable Care Act. Your hospitalization insurance is generally designed to pay a good portion of the costs related to an illness or injury so bad that your doctor feels you need to stay in the hospital for care. However, it never did – and still will not – pay all of those expenses.

Before the Affordable Care Act, some insurance policies treated any hospitalization costs as an option, not in the standard policy. Obamacare insists that all health insurance policies have some hospitalization benefits included. But it doesn’t say specifically what is to be covered. Like all other provisions, the specifics will vary according to the State you live in and the company you buy from. Each State can set its own rules within the general category of hospitalization. And those rules should be based on what the average employer’s health plan has covered in that State.

Basically that means that your hospitalization insurance doesn’t have to cover all the care that you might go to a hospital to receive. There are two general divisions of professional medical care. They are known as ‘Medical’ and ‘Surgical.’ Surgical care, of course, generally involves cutting and stitching. Medical care covers everything else. And people are hospitalized for both kinds of treatment. Not surprisingly insurance coverage for each varies from company to company and plan to plan.Surgery

Surgical Coverage

One would expect that emergency surgical care that saves lives would be covered by hospitalization insurance. And ‘elective’ surgery, which often improves your quality of life rather than saves it, might very well not be. As in policies built before Obamacare was passed into law, many insurance companies will most likely limit hospitalization coverage to ‘medically necessary’ treatment. Fortunately, what is judged medically necessary can vary from plan to plan. Elective surgery could include procedures like:

  • Biopsies or exploratory surgery used to diagnose an illness or determine how advanced it is.
  • Female surgery like cleaning out or removing the uterus.
  • Joint replacements.
  • Eye surgeries used to take out cataracts or improve vision.
  • Plastic surgery to reconstruct or repair parts affected by illness or injury.
  • Surgery to improve the heart’s function.

Doctors see some of these surgeries as important for improving your quality of life even though they are, technically, elective surgery. Other procedures they may not see that way. The main thing that goes into insurance carriers’ decisions about covering a procedure is the question of need. Still, some insurance companies, but not all, will cover a surgery they think will save the company money down the line and maybe keep the client from getting sick – even though it’s not technically necessary. For example:

  • Eye surgery that will keep you from needing eyeglass and contact lens prescriptions in the future.
  • Sterilization – because they won’t have to pay for birth control prescriptions, abortions or childbirth in the future.
  • Weight-loss surgery to decrease the likelihood of an obese person having future weight-related illnesses.
  • A nose job that fixes breathing problems – but not one just for changing the size or shape of your nose.

By the way, Ostetrics is considered by the profession to be a Surgical specialty!

General Medical CoverageMedical care

This type of care covers conditions that are treated with drugs, diet, exercise, and other nonsurgical means. The kind of problems we are talking about include conditions relating to:

  • heart disease,
  • diabetes,
  • cancer,
  • breathing problems,
  • stomach and bowel malfunctions,
  • mental illness,
  • and many other things.

Again, one would think that treatment for such a condition when it is threatening the life of the patient would be covered by your hospitalization insurance. And it will be now. It generally was in the past, too – the first time you showed up with the problem. And if you kept the same insurance plan from the same employer, additional care would also be covered. But in the past, if you changed plans, you might be out of luck. You see, many insurance companies found they spent a lot of money on people with these problems because they frequently came back into the hospital for treatment over and over. So when you signed up for a new plan, they did one of two things –

  • they charged a very high premium to cover care for a condition you already had before you got the policy, or
  • they put a clause in the policy excluding ‘pre-existing conditions’ and just didn’t pay for treatment if you had ever had the problem before.

One of the provisions of the Affordable Care Act requires all major medical insurance to include pre-existing conditions – at the same ‘affordable’ rates everybody pays. When you learn about how the insurance business works, you find out that you can expect insurance premiums are going to have to go up for everybody when more sicker people are getting covered.

Find out what hospitalization insurance benefits you can buy

Standards of medical and surgical coverage are not written into the Obamacare law. It just says that the Secretary of Health and Human Services should define it. And that office has left it up to the individual states to set up the standards in their territory.

Health Insurance PolicySo here we are again – Just what specific coverage health insurance plans under the Affordable Care Act offer in the way of hospitalization benefits is likely to be different in different states and with different companies. It’s up to you to find out what is available for you. And you can do that by getting on the government’s website healthcare.gov and viewing the health care plans available to you. If your state has its own exchange, you will be referred to it for that information.

Another option is to go to a local insurance agent. Or you can use one of the private health insurance marketplaces on the web like eHealthInsurance.com. They are up and running, have free consultants to answer your questions and help you through the process of evaluating, choosing, and applying for affordable health care insurance. With the ambiguities of the law, you’ll surely want to ask specifically about hospitalization coverage.

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