Question: My mother fell and broke her hip. She was admitted to the hospital and her bill is $360 per day. I thought Medicare paid it all?

Answer: I hope your mother is recovering from her recent fall. This can be a very scary time for all of you. After the anxiety settles down from the actual incident, people begin thinking about “How much will this all cost?”

To answer the question “What is the cost?” we must first know what type of insurance you have. Original Medicare alone, Original Medicare with retiree coverage (like SKF Loomis), Original Medicare with a Medicare Supplement (with 10 available options) or a Medicare Advantage Plan (54 options available). Each one of these insurance products will result in a different answer as to what a hospital stay will cost.

Original Medicare has a deductible of $1600 for each hospital admission. If your mother has a retiree plan acting as secondary, it most likely will cover part or all of the $1600 deductible, leaving your mother a smaller amount or not paying anything.

If your mother has a Medicare Advantage Plan, her Original Medicare will not pay towards any of her healthcare as the Medicare Advantage (MA) Plan will be primary and only insurance. Each of these MA plans have different copay structures for health care, but a co-pay of $360 per day sounds about average. The co-pay days are usually limited to 5 or 7 days for each hospital stay. Some MA plans offer a maximum out of pocket for hospital stays in a year. For instance an $1800 maximum out of pocket for hospital stays would be five days at $360 per day. So that means she would only pay for five hospital days in a calendar year. If she were hospitalized multiple times in the same year she would only pay for five days in that year.

If her plan does not have a maximum out of pocket for hospital stays, it would mean she could pay up to five days at $360 per stay for each hospital stay. Multiple hospital stays could really add up. All MA plans have a maximum out of pocket for health care each year, but that could be as much as $7550 for an HMO and $11,300 for a PPO in 2023.

Before and after the hospital stay there will likely be other costs. The ambulance ride to the hospital will have a cost. The rehab after her hospital stay will likely have a cost. The ride home or to the rehab facility in a transport van will likely have a cost.

An ambulance ride to the hospital could be covered in full or could be a co-pay around $300. The transport van could be covered or could be $100 or more depending on the distance. The rehab stay will likely be covered in full for the first 20 days and then potentially additional copays for additional days in the facility. All of these potential costs are determined by the insurance plan your mother has.

When picking an insurance plan, usually the factors considered are the monthly premiums your mother pays the insurance company, and the medication co-pays at the pharmacy. Most of us like to believe we are going to be healthy and not need significant medical care. When and if that significant medical problem comes along, we recommend people re-evaluate their insurance plans.

There are Special Enrollment Periods (SEP) that may be used to allow your mother to switch her insurance to a plan that is more appropriate for her current medical situation. This switch cannot change what has already happened, but it can be used to find a plan with more appropriate coverage for her current health situation.

Our lives change in unexpected ways and it is good to know that those with Medicare Health Insurance have ways to change their insurance to better meet their current health needs.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or e-mail at SLM@lutheran-jamestown.org.