Understanding your share of costs associated with healthcare procedures you receive can be confusing. This hospital is committed to helping you understand your share of the costs.
Financial counselors are ready to assist you. Also, please review all of the information on this webpage in order to better understand the price of your care.
Here is some of the basic information you will need in order for the hospital to help provide you with information about the price of your procedure:
Your Health Insurance Coverage.
Please have your health insurance coverage information available.
You might have commercial health insurance through your spouse, through your place of employment or that you purchase on the individual market. Some of the larger health insurance companies in Maine include Anthem, Aetna, Cigna, Harvard Pilgrim and Maine Health Options (CHO), among others.
You may have government-sponsored health insurance such as Medicare, Medicaid (also known as MaineCare) or veteran’s benefits.
You may be uninsured, or pay out-of-pocket, for all of your health care costs.
Please have either the name of the doctor or other medical professional who is referring you to the hospital for care, or the name of the doctor who is performing your procedure at the hospital.
A Description of Your Procedure.
Please ask your doctor to provide you with a specific description of your procedure. For example, “back surgery” is too general a term for the hospital to be able to provide you with a price estimate. There are many types of surgeries. The more detail you can provide, the easier it will be to provide an estimate. If possible, ask your provider for the code associated with your care.
Hospital Contact Information.
In order to receive an estimate of the price of your procedure, please contact:
- Telephone 207-255-0473
- Email email@example.com
- In-person Brandis Townsend
Federal law guarantees that you have access to emergency care at hospitals, even if you can’t pay for the care. If you do have health insurance or you can afford to pay for your care, you will have the responsibility to pay your share of the cost of your care.
Due to the sudden and unpredictable nature of emergencies, the hospital will likely not be able to provide an estimate of the cost of care before stabilizing the patient. However, the hospital is committed to providing you with information about the cost of care. If you have questions, please ask to speak with a financial counselor before leaving the Emergency Department.
If You Are Uninsured.
This hospital is committed to providing medically necessary care to anyone, regardless of their ability to pay. Depending upon your financial situation, the hospital may waive some or all of the costs of your care. Please ask to speak to a financial counselor and ask to see the hospital’s financial assistance policy or charity care policy. [22 MRSA §1716.]
If you have health insurance, your insurance company may or may not have a contract with this hospital. If they do, this hospital is considered “in-network”; if not, this hospital is “out-of-network.”
If this hospital is “in-network,” your health insurance company and this hospital have an agreement about what services should cost. Also, any share of those costs for which you are responsible will be part of the co-pays and deductibles.
However, if this hospital is “out-of-network,” your health insurance company will require you to pay out-of-pocket a greater share of the cost of your care. Review your health insurance contract and speak with your health insurance company if you have questions about your network.
Under the law, treatment for emergency care by out-of-network hospitals must be treated by the health insurance company as if it were in-network. Meaning, your co-payments and coinsurance may not be higher just because you go to an out-of-network hospital.
Third-party Providers of Care.
For some procedures in the hospital, not all of the medical professionals involved in your care are employees of the hospital. For example, some of doctors who perform surgery, some of the radiologists who read x-rays and some of the anesthesiologists are not employed by the hospital where you are receiving care.
These independent medical professionals are considered “third-party providers.” Accordingly, they may send you separate bills for the services they provide to you while you are at the hospital. If you would like to know about the prices of their services, please contact these providers.
If you are unsure of whether your care involves third-party providers, ask the hospital. The hospital will provide you with contact information for any third-party providers involved in your care. [22 MRSA §1718.]
Prices Do Not Necessarily Equal Out-of-Pocket Costs.
When you receive a price estimate from this hospital, please keep in mind that this is likely not the amount you will pay out of your pocket for the procedure.
If you have health insurance, your out-of-pocket costs may be much lower. You need to consult your policy and speak with your insurance company to determine your share of the costs.
Generally speaking, health insurance companies pay the largest share of the cost of most health care procedures. However, your insurance company might require you to pay a co-payment or co-insurance.
A co-payment is typically a flat fee for receiving a service, such as the amount you pay to visit a doctor or fill a prescription.
Co-insurance is typically a percentage of the total price of a particular service, such as the insurance company will pay 80% and the patient will have a co-insurance responsibility for the remaining 20%.
A deductible is the amount you pay for healthcare services before your health insurance company begins to pay. A deductible is typically a fixed dollar amount such as $1,500. This means that you may need to pay $1,500 for healthcare services before your insurance company pays. The amount you pay for monthly premiums does not count.
The amount of your deductible can vary significantly depending on whether you have individual insurance coverage or family coverage and whether you have a “high” deductible plan or a “low deductible” plan. And remember, the amount of your deductible also depends on whether you’ve consumed any healthcare services this year.
The policies related to co-pays and deductibles also can vary significantly if you have government health insurance such as Medicare or Medicaid.
So, please contact your health insurance company to understand your share of the price of your health care procedure.
Charges vs. Prices.
The federal government requires hospitals to keep a list of “charges” for all procedures the hospital performs. You may see that list price in different places. For example, if you have health insurance, the “Explanation of Benefits” that you receive from your health insurance
company will frequently include a ‘charged’ amount for your procedure. However, that is typically not the actual price for the procedure. Health insurance companies and government payers frequently negotiate, or impose, lower prices called the “allowed amount.” The allowed amount is the actual price for the service.
Is It Covered?
If you have health insurance, please remember that health insurance policies do not cover all procedures. These procedures are often called “elective” by your health insurance company if it deems the procedure is not medically necessary. Consult your health insurance plan description and contact your insurance company if you have questions about whether a certain test or procedure is covered.
If you are receiving a medical procedure like surgery, your price estimate may reflect a range of prices rather than a single amount. That is because surgeries can involve unknowns, unanticipated risks or other complications that can increase the cost of your care. Ask your doctor to describe the kinds of potential complications associated with your care.
If you have commercial insurance and need to contact your carrier, below are links to the major commercial and government entities.
State of Maine Bureau of Insurance.
The State of Maine has a Bureau of Insurance that can assist you with complaints or problems with your commercial insurance carrier.
Please note, the Bureau of Insurance does not have authority over all insurance providers.
Maine Health Data Organization.
The State of Maine established the Maine Health Data Organization (MHDO) as an independent executive agency to collect quality and financial healthcare information and to exercise responsible stewardship in making this information accessible to the public.
Please note, the pricing data presented on the MHDO webpage may not be the same as price estimate information provided by the hospital. Some of the significant differences include:
- Average Price: The prices on the MHDO CompareMaine website are average or median prices paid by all of the large insurance companies in the state. The price paid by your insurance company will likely differ from the average.
- Total Price: The prices on the MHDO CompareMaine website include the combined amount paid by the insurance company and the patient. The hospital likely will not know what sort of payment arrangement the patient has with his/her insurance company.
- Bundled Price: Many of the procedures displayed on the MHDO CompareMaine website are for an entire episode of care. The episode is all care received 30 days prior to the hospital visit and 30 days after the hospital visit. For most procedures, the web-site also bundles the care provided by multiple different doctors and facilities. The hospital likely will likely only be able to tell the patient the price of the care provided at the hospital as opposed to the entire episode of care.
- Dated Price: The prices listed on the MHDO CompareMaine website are approximately a year old. Prices change over time so the prices on the website may be outdated.
- Healthcare Financial Management Association – Understanding Healthcare Prices: A Consumer Guide
- American Hospital Association – http://www.aha.org/
- Centers for Medicare and Medicaid – Hospital Compare
CMS Required Hospital Charge Data
As required by the federal government (Centers for Medicare and Medicaid Services), we publish information (a comprehensive machine-readable file) about the rates negotiated with insurance companies for all services and items offered by our hospital. This file is listed below and available for download.
The price information contained in this large file is NOT an estimate of the costs that you are responsible for paying. This file is not intended for patients and does not reflect your out of-pocket costs. If you are a patient, you can request a cost estimate by contacting Patient Financial Services at #207-255-0473.
This file is updated once a year, but prices and contracted rates are updated during the year and these updates may not be reflected in this file.
Top 50 Service Charges.
Maine law requires hospitals to have a list of their most frequently provided healthcare services and procedures. The prices stated must be the prices that the healthcare entity charges patients directly when there is no insurance coverage for the services or procedures or when reimbursement by an insurance company is denied.
This hospitals list of Top 50 charges may be found: Click Here
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
Contact DECH Patient Financial Services at 207-255-0473 if you have questions about your bill.