Understanding Insurance Benefits When You’re In the Hospital

with Robin Peconge,

Naviguide, United Church Homes

This week on Ask a NaviGuide, we chat with Robin Pecogne, one of our NaviGuides at United Church Homes. During the episode, Mike and Robin discuss insurance benefits, namely in what insurance covers during a hospital stay. The conversation also includes understanding deductibles and out-of-pocket maximums, advanced directives, and more.
Play Video


Highlights from this week’s conversation include:

  • Robin’s background in the healthcare industry (0:46)
  • What information do I need as part of the intake process for a hospital stay (2:24)
  • What do you pay for and what does insurance pay for? (5:10)
  • Questions healthcare providers will ask about your insurance (6:53)
  • What is an advanced directive? (9:35)
  • Steps to take in checking into a skilled nursing facility (12:43)
  • Understand deductibles and out-of-pocket maximums (15:38)


The Abundant Aging Podcast series is presented by United Church Homes. These shows offer ideas, information, and inspiration on how to improve our lives as we grow older. To learn more and to subscribe to the show, visit abundantagingpodcast.com


Michael Hughes 00:07
Hi everybody, and welcome to Ask a NaviGuide part of the abundant aging Podcast Series. I’m Mike, your host. And on this show we tackle subjects in aging and family caregiving that can be stressful to work through. And we do this with tips and advice from the United Church Homes NaviGuide team. Our NaviGuides have decades of experience helping families work through these issues, and we want to help everyone everywhere, age with abundance. Today, we’re here with Robin, who will help us understand insurance benefits, and more specifically, insurance benefits where you or a loved one may be in the hospital, and try to understand when you’re in that situation, how to navigate those insurance benefits. And hopefully, our advice will help you out and lower some stress. So Robin, I don’t know you wanna give yourself a quick introduction? Sure. Hello, thank

Robin Peconge 00:55
you for having me. So I have about 20 years experience working in the senior health field that would include long term care insurance, Medicare Advantage, Medicare Supplements, life insurance, that type of thing, I have a little bit of a couple years of experience in claims as well as I was a billing manager for a home health care for about five years before becoming an avid guy. So I do like to use my experience to really, I know insurance can be very overwhelming, especially for seniors moving from the employer retiring and then going into Medicare. So this is what I love to do.

Michael Hughes 01:27
That’s awesome. Well, thank you so much for being with us. And by the way, I want to do a future podcast on long term care insurance, because that’s an interest. That’s an interesting subject. So we know it can be really stressful on families, when a loved one has to go into the hospital and even more stressful that hospitalizations, unplanned and one day turns into another day, another day may turn into even weeks. And that’s pretty hard. And we all know about those horror stories about people that you know, they racked up millions of dollars in health insurance, or health care costs and all the rest of it. So it can be really unsettling. What I’m saying, you know, is when you’re dealing with your loved one, you don’t know how or when you’re gonna get better. And then you’re thinking about insurance. So today, I’d love to see if maybe you can walk us through a process or some ideas that families can use to better understand what insurance covers and what they may have to cover. So they can be better prepared, and maybe, you know, we can give them some peace of mind. Okay, so are you ready to get into it? I’m ready. Okay. All right. Question number one. What are some of the important things you should understand if you have, say, an unexpected hospital? So let’s say this starts out with an ER visit, right? Something happens, I’m an ER visit, I guess, what are some things maybe to either to have already or to know that you would have to provide as part of a intake process,

Robin Peconge 02:47
Certainly, you want to make sure you have all your insurance cards with you, that usually happens. But having a list of your medications is very important. You know, oftentimes, even here locally, we have two large hospital networks, and you’re usually in either one or the other. All your doctors might be in that network. But you’d be surprised if you go to the hospital in that network that they may or might not necessarily have the most recent list of your medications. So whether you have a list handy, whether you have all of your bottles and a great big gallon bag, however you need to do that. That’s very important. So those are the main things. One thing I recommend is you can actually go on. It’s called Light boiler. It’s a red magnet that you can put on your refrigerator. And most first responders are trained to look for those if they have to come to your home to take you to the hospital. On that you would have your demographic information, your insurance information, there’s a spot for your medications, or what I typically recommend is normally when you leave your doctor’s office, they almost always give you a list of your medications, you can just fold that up, put it in there, that way they know how old it is. And that’s what I recommend. Or if you’re just driving to the ER, you can just simply simply grab that. And you would have everything that you would need. Wow.

Michael Hughes 04:01
I mean, this is just part of emergency preparedness, right? It’s like having like if you live in an area where they have tornadoes or things like that you have sort of a grab and go bag. I mean, there’s Life Alert. Yep. Another similar. Yeah, grab and grab and go. Let’s first sorry, lifeless first responders are trained to look for this.

Robin Peconge 04:18
Yes, I know, in my area, they are Yes. It’s the magnet that goes on your refrigerator. We also put a sticker right outside their door if they live in an apartment complex. So they also have to look for that.

Michael Hughes 04:28
Oh, that’s terrific. That’s terrific advice. And, you know, if you don’t have this list, I mean, I’ve heard stories about people, you know, usually when they go to the hospital, the Heart Hospital has their own kind of pharmacy in the building, right? If you have a condition, they may prescribe you the very same medication that you have at home or they may because they’re not necessarily one network may not sit and talk to another or they basically be covering their bases. You have those meds on the way back right but they may just be duplicated or different doses or things like that, and that can kind of mess things up. Right? Right. You

Robin Peconge 05:00
I’d like to make a correction. That’s actually called a file of life magnet not Life Alert. I do apologize. Oh,

Michael Hughes 05:06
Okay, so sorry. Sorry, let’s go back to a file of life magnet. Okay. All right. free advertising? Yes. So how does your insurance even know that you’re in the hospital? And how would it start organizing what you pay for and what they pay

Robin Peconge 05:19
for. Really, that won’t happen until after the fact until the claim comes. So you know, if you have a planned visit, of course, they’re going to do prior authorization, they’re going to make sure that you’re, you know, you’re covered. But when you go to the ER, you know, hopefully, you already know that that network is in your network and that sort of thing. But really, they won’t be notified until they get a claim.

Michael Hughes 05:40
Got it. Okay. But if it is a plant hop, like I’m in for, you know, a plan surgery or something like that, you’re still gonna bring your medication list, right? Yes, you’re still gonna bring your insurance card and all that, but then you’re the hospital will likely probably call your insurance provider to make sure that they’re in network. Yeah, that there may be an undersea. So in that situation? I mean, would you if you want to understand maybe what you would be responsible for, and the insurance company would be responsible for if it’s a planned hospitalization? Would you be calling the insurance company? Or would you call the hospital billing department just to get maybe a ballpark of what your responsibility is,

Robin Peconge 06:19
I don’t know that you can get a ballpark that you can certainly call the hospital billing department and ask, you know, who are all the providers that are going to be performing my surgery? And then you can call your insurance company and say, This is who will be there? This is what I’m doing? Let’s say it’s a hip replacement, knee replacement. Is there anything you foresee that has not been done yet? Are there any extra prior authorization guidelines that I have? If I need therapy afterward? Is there anything that I need to know ahead of time to prepare for that? If I have to go to a skilled nursing extended care rehab stay? Is there anything I should know about that? So those are the things that you should try to do to prepare ahead of time?

Michael Hughes 06:57
So let’s talk about what happens from the hospital perspective, when you are admitted with planned or not, let’s say it’s unplanned, okay. Okay. So how would the hospital? What would they do during a state? Or how would they begin to understand your insurance information? What might they ask you? Or maybe your loved one or your caregiver? Or caretaker? What would happen? What would they be required to provide? I guess, I don’t know what’s normal and what’s not normal. Like, when, when, when you’re let’s, let’s say that my spouse is in the hospital, you know, I can’t even think about insurance situation, but they’re asking me about these things, what’s normal for them to ask and what’s not normal for

Robin Peconge 07:35
them. So the only person that might have an inkling would be the case manager. And this would be once you know that you’re going to be discharged. And to be honest, I don’t think they know much more than making sure that you go someplace that then network. Okay, so they’re going to, they may come in, and they’re going to say your loved one is doing better, but they’re to the point where we’ve done all that we can do for them here. Because really, hospitalization is just getting the person stable, and then they need to go somewhere else. That’s what a hospital there’s a lot of people don’t realize that they’re like, why can’t they just stay here, you guys, you know, are doing a great job they can be looked after. But a hospital is really just for that short term stay. So whether it’s going to an extended care facility or home health care, it’s time to move on to that next level of care. So they may come to you and they do have a preference on what facility that you go to for your therapy. Normally, the difference is on whether you can go home or not, is when you’re in a nursing home, you’re getting therapy every single day, sometimes couple times a day, when you get to the point where you only need it two or three times a week, then you’re appropriate for home health care part a therapy. So it’s all about the continuing therapy as you’re improving and just you just need less than less. So you know, you, you may need to have a couple of areas in mind as there are some facilities that are close to your home or close to your work or whatever is going to make it most convenient. As well as being in a network, they might be full, you know, a lot of extended rehab sites have just a very, you know, few beds anywhere from five to maybe 20. Because they’re there mostly for the long term care patients or memory care. So you might need to have a couple of those in mind. Some of those may choose not to be in network with Medicare Advantage plans because filing claims is a little different from those than it is with Medicare. So, you know, that can be very overwhelming. If someone’s coming to you and saying, Here’s a list of places, which one of these do you want? He or she to go to? Wow, yeah, that is allowed to make recommendations.

Michael Hughes 09:39
It’s the patient’s choice or it’s your choice. Okay. So if I have to make a decision for a loved one in the hospital, I should expect that I guess on the intake, they’re gonna be asking me for the insurance information. They also asked for things like advanced directives, right? Yes. Okay, so it’s common to ask for advanced and advanced directives is what

Robin Peconge 09:59
Advanced Direct Debits can be several things. But in this particular case, a lot of times it’s do you want to be resuscitated? Should that event arise. And what that means is people a lot of times think that you might just be passed out, but still breathing and everything and you’re and they’re asking you to do what you want someone to help you. And that’s not what that means. That means that if they come into your room, you have no heartbeat, and you are not breathing. What do you want them to do?

Michael Hughes 10:24
Yeah, and it also so it’s a living will? And would it? So let’s say I’m, you know, let’s say my wife’s in the hospital with the Advanced Directive also say, This is my husband? And, you know, he can make certain types of medical decisions for me, if I can, yes, for myself, yes.

Robin Peconge 10:43
Well, typically, your living will is going to pretty much lay out what it is you want. But that gives him the ability to legally sign the paperwork saying this is what you want. So I got it. Okay. So obviously, if people don’t have that, or if they don’t have a very detailed one, yes, that also gives that person that right to make those decisions. But hopefully, if you did it living well, you have it laid out exactly the way you want it.

Michael Hughes 11:07
Yeah, and I think we may, you know, living wills and advanced directives, may be something that we want, we want to cover on a future podcast, Robin, because I think that’s important for people to understand. Cuz I don’t think a lot of being just having a living will or having a will or having an Advanced Directive. I mean, not everybody has those, right? You have yourself. Right. Okay. All right. So different that we’ll cover that on a future podcast. But let’s go back to case managers, if I’m in the hospital, there’s just so just in that, first stop, on the road to recovery, or whatever, whatever you want to call it, there’s gonna be a case manager there. And that case manager is really looking at my loved one and saying, you know, he, she they are, they need to stay here for longer because they’re not stabilized. Once they are stable, that person will move, they can move to a skilled nursing facility or similar where if they deem that they’re not, they’re not they can’t go home, they need daily therapy or things like that. So you’re teaching me so well, this is awesome. And then if they say, Oh, well, they can actually go home, and maybe they need services a couple times a week, then this is home health. Yeah, and the case manager will, you know, these are, these are facilities, they’ll present you a list with facilities that are in their network. And then they’re also going to check for availability of a bed or a place. Or if you’re talking about a skilled nursing facility, right?

Robin Peconge 12:27
Well, they’ll give you a list, but they won’t necessarily know if they’re in the network until you pick one. And that’s why you need to have a couple in mind. So you’ll say How about this one? I think I’ve heard of this one before? And maybe this one, then they will call them and say this? Is the resident? Or this? Is the patient that we have this what their needs? This is what their insurance is. And then then they’ll find out if they’re in network or

Michael Hughes 12:46
not. Got it? Okay. So if you’re so, they’ll give you a list of these facilities, and then you might want to check them out, right? And what are some steps that you should take to check out a skilled nursing facility to know if it’s a good one or not,

Robin Peconge 13:01
you can go on.gov. And there is a list and there’s a star rating for these types of places. Unfortunately, it’s not in real time. So it could have been usually at least 90 days old. So maybe that they’re with revision they had worked on, there’s been a plan of correction. So you know, you do have to take that with a grain of salt. You know, I tell my residents that I work with that none of them are going to have good food. What if what you want to look for is what type of therapy department do they have? You know, that’s why it’s important to have a good support system, you still want Stanley to come in there to provide you with some snacks and things that are going to be like home, but you’re really not wanting to look at, obviously, you want it to be clean. But a lot of times the newer places are not the places to go, this is kind of my philosophy on what I’ve seen is you might have a brand new, beautiful nursing home, but they’ve hired everybody that everybody else has let go. So it might take a couple of years to get a good strong staff to get good strong medical professionals. The one that has been there for a long time, that has not had a lot of turnover, has a great therapy department. That’s mainly what you want to look for.

Michael Hughes 14:19
That’s, that’s the Goldilocks kind of, and it’s and look, you know, you know, you’re going on while you go into medicare.gov You’re looking at the facility, they have the star ratings, which I guess you know, like, you know, that they’re based on things like, do people go back to the hospital too often from this facility? Do they have sections? Do they have things like that? And I mean, there’s no harm and actually calling the facility up and just sort of saying, Hey, I noticed that this or this or that? That is an issue here. Can you speak to that and I guess a good facility will say Oh, yeah, we’ll you know, we’re dealing with this or right I mean, they’ll tell me where you are. Okay. Yeah,

Robin Peconge 14:56
they should be transparent. You know, they should

Michael Hughes 14:59
I mean, we always Yeah, we always sort of tangent. Well, I tend to hit on these topics when we do these discussions, Robins, but it’s all just great information. Well, and

Robin Peconge 15:09
you were starting to see pop up, and I know we have never died. But there are a lot of others, you’re starting to see that more and more where the hospitals might have a third party come in, because either their case managers are overloaded, or because they simply aren’t as knowledgeable. But there are, you know, a lot of the care coordinators care navigate or navigation. So it’s all kind of the same thing. But we’re going to have a guide. Yes. So we are called navigate. Okay, okay. Well, we’ll

Michael Hughes 15:37
we’ll give the plug later. But an important question. And we’re gonna close this one out. So in the insurance itself, I know that if I have employer based insurance, I would have maybe, depending on my plan, I would have what they call a deductible, where I would have to cover a certain amount of costs before the insurance covers the costs. And then I have an out of pocket maximum, right? Yes. So let’s say that I’m in the hospital for like, my loved ones have been in the hospital for a week. And I’m starting to get anxious, because I know that, you know, that I’ve, I’ve had to pay copays before I’ve had to pay bills before I’ve had this experience of maybe I had a surgery before. And suddenly I get the doctor bill and the anesthesia bill and things like that. And that’s all like, Oh, my goodness, what’s happening here? But can you talk a little bit about how, let’s say we’re talking about a medical event that may be significantly expensive? For and that’s what insurance is for insurance is for them to? How does that work in terms of understanding my deductible, and my out of pocket maximum? And what I’m responsible for and what the insurance companies are responsible for?

Robin Peconge 16:51
Well, hopefully, that all had that conversation when you first met with your broker. So you at least have an idea. If you have if you’re in a PPO network, I would say a common maximum out of pocket is around $3,400, maybe between $3,400.06 and $1,000. Now,

Michael Hughes 17:09
we’re talking about here, 2023, February 3 2023, in around, okay.

Robin Peconge 17:15
Now, granted, if you’re out of network, that could be more, but hopefully you will have an idea of that. And also keep in mind, you won’t see those claims for a while. Not only do they have to be processed, they have to go through their network to be discounted, before it’s ever sent to you. And there’s going to be some of that written off. So it’s going to be a while before you have that, you know, they set up payment plans, they work with you. So they don’t expect payments. As soon as they

Michael Hughes 17:41
So let’s say. So I’m in the hospital, I’ve been there for a month, I’m gonna just make up an extreme. And let’s say I’m in the hospital in December. Okay, I’ve been in there for a month, and I’m going to be in the hospital for January, and I’ve been there another month, the maximum amount that I’m personally responsible for is going to be the out of my out of pocket maximum spending level, right? So if it’s $3,500, then and if I haven’t met that, let’s say I haven’t done anything in December health wise. So in December, I pay 3500 bucks, or 3600 or 4000, whatever it is, in January pay 30 630, whatever it is $4,000. And that’s it. And the insurance company pays for the rest of the benefits that are covered under my insurance plan. Right?

Robin Peconge 18:31
That’s a tricky question. Because if you look at your Summary of Benefits, it could say that you’re just responsible for the first five days, not necessarily the fact that you’re in one benefit period versus another. So and also, let’s see, if you took, you know, most people’s effective date is January 1, because of the annual open enrollment, but not necessarily. So your effective date could be from the time that you actually signed up for that program. So there’s a lot of questions there.

Michael Hughes 18:59
So if I’m taking care of a loved one in the hospital, I’m calling up the insurance company and I’m saying hey, what’s the what’s my responsibility here? Right? And they’ll lay it all out for you, right?

Robin Peconge 19:07
And if it’s traditional Medicare, they actually have their benefit periods for 60 days if every 60 days. So when it matters if it were in December and January over that change of yours.

Michael Hughes 19:19
Oh, so it’s rolling for 60 days, so it wouldn’t be okay. Oh my gosh, it just gets more and more complex when you get deeper and deeper into it. But your loved ones in the hospital call up the insurance company to explain the situation. Don’t be shy. You don’t want surprises. You know, have they laid out you know what you’re responsible for? Plants responsible for Okay, right. All right. Well, look, we have to wrap it up for this one. This is just fantastic. Thank you so much for sharing your knowledge Robin. And, and again, we may be covering this on a future podcast. If you the listener have questions or want to have a subject We should cover please send that to us on our podcast site. And if you want more information about the UCH NaviGuide program, please visit www.uchnaviguide.org. And for more information about United Church homes, please visit www.unitedchurchhomes.org. So thank you very much for listening this time and we’ll see you on the next one. Thanks all!