Understand Gillette Costs, Estimate Your Price

Knowing the cost of your care is important. At Gillette Children's, we do our best to provide patients and families with financial resources and information early in the decision-making process. With the help of our financial advocates, you can be better informed about your health care costs.

You might find that costs at Gillette Children’s are higher than they are at some community clinics—there’s a reason why. To best serve children, teens and adults who have rare and complex conditions, Gillette operates differently from other hospitals:

• You work with a team, led by our board-certified physicians, to coordinate and provide care.
• You get all the services someone with a particular condition requires—everything from imaging and diagnosis to surgery, rehabilitation therapy and related services.
• You get more time for appointments.

Learn more about the quality of care we provide.

A hospital-based clinic (HBC), also known as a “provider-based clinic,” is owned and operated by a hospital. It’s a common and well-known practice, for a hospital which owns and operates both hospitals and clinics, to operate HBCs. When you see a doctor or receive services at an HBC you’ll be billed as if you were in the hospital. This is because the HBC is an extension of the hospital.

How is billing different for a hospital-based clinic?
The billing structure for hospital-based clinics (HBCs) is different from a stand-alone doctor’s office. The fees for HBC services are separated into two parts. These may be billed separately or shown separately on one billing statement. The two parts include:

1. The hospital charges, or “facility fee.” This includes the cost of nursing and other non-doctor medical staff, supplies, equipment, treatment rooms, and other building expenses. The facility fee applies to different kinds of services provided as part of a HBC visit, including tests and procedures.

2. The professional charges, or “provider fee.” This is for professional services provided by the doctor or other providers.

Health insurance plans and programs pay in different ways for services provided by HBCs. For more information on your plan, please ask your insurance company how they cover facility fees. Your insurance may or may not cover the facility fees or may cover them under different patient responsibilities for payment. The patient may be responsible for paying a percentage of the bill (co-insurance) and/or meeting their deductible.

What is the cost of the facility fee?
The amount that Gillette Children’s charges for facility fees will depend on the following:

· the length of the patient’s visit

· the services received during the outpatient clinic visit. Visits that require expensive supplies or equipment will generally result in higher facility fees.

· For facility fees and other cost estimates, you can call the Financial Advocate Line at 651-325-2235.

The amount of the facility fee that a patient will be responsible for paying out of pocket depends on the patient’s health insurance coverage. Any amount you owe will be based on the specific services you receive and your insurance plan benefits.

We strongly encourage you to contact your insurance company to determine their estimated financial responsibility for a facility fee, including co-payments, co-insurance, and deductible amounts.

What should I ask my insurance company?
If you have private health insurance or secondary insurance, ask your insurance company:

· Does my plan cover hospital/facility charges in a hospital-based outpatient clinic (or a “provider-based clinic”)?

· What percentage of the charge is covered?

· If covered, how much will be applied to the deductible?

· Is there an additional amount I’ll have to pay out of pocket, for any co-insurance responsibility?

How will I know if my visit is scheduled at a hospital-based clinic?
All of the Gillette Children’s metro clinics, St. Paul, Phalen, Maple Grove, and Burnsville clinics, are hospital-based clinics. Signs at the clinics will also identify the clinic as a department of a hospital. If you are unsure if you are visiting a hospital-based clinic or have questions, call our Financial Advocate Line at 651-325-2235

We want you to be informed about the price of the medical services your family needs. That’s why we put together our Shoppable Services, the 300 most common services our patients receive, and their relevant charges. 

Review Our Shoppable Services

The prices in the document do not consider your individual health or financial situation. Contact a Gillette Financial Advocate for an in-depth assessment of your out-of-pocket costs at 651-325-2235.

Health care pricing and medical billing can be complicated. Certain factors, such as the actual services performed or changes in your insurance coverage, may affect the amount you owe. We understand your concerns about the cost of health care and want to help you address them. Your final billed charges will be reflected on a final billing statement, which will include all hospital charges, such as charges for room, equipment use, supplies and services provided by Gillette.

Our goal is to make sure the comprehensive, expert care we provide is available to any family who needs it. We have financial resources like the Gillette Assistance Program (GAP) and our Gillette financial advocates. Our financial advocates are available to help you calculate a price estimate that includes your insurance coverage and financial support options.

Contact a Gillette Financial Advocate for an in-depth assessment of your out-of-pocket costs at 651-325-2235.

Our goal is to make sure the comprehensive, expert care we provide is available to each family who needs it. Gillette has many resources to help you afford the health care you need. Contact our financial advocates to determine if you qualify for any financial assistance or ask questions at 651-325-2235.

Many Gillette families qualify for the Gillette Assistance Program (GAP). We established GAP to help our patients cover current bills, future copayments and deductibles. Eligibility for the financial assistance program is based on family size and income.

We recommend contacting a Gillette financial advocate for a more accurate price estimate that assesses your financial situation, including type of insurance, co-pays, deductibles and ability to pay.

Our team of financial advocates is ready to help. Email estimates@gillettechildrens.com or call 651-325-2235.

When you call a Gillette financial advocate, they can help you:

• Put together an in-depth estimate of your care cost, including your insurance coverage and financial assistance.
• Work with your insurance provider(s) and/or Medical Assistance to get details about benefits and coverage.
• Find out if your insurance requires a referral or physician’s order.
• File an appeal if your insurance provider denies your request for care at Gillette.
• Understand the bills you receive from Gillette.
• Set up a payment plan, if needed.
• Apply for financial assistance through the Gillette Assistance Program.
• Learn about grant opportunities from UnitedHealthcare Children’s Foundation.
• Discuss our list of standard charges.

We always keep your questions and personal information completely confidential.

Contact a Gillette financial advocate 30 days before your visit so that we can get the facts you need. Make sure you have:

• Your health insurance card/cards, if any.
• Your Medical Assistance card, if any.
• The name of the policyholder for your health insurance coverage, if any.

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. 

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, 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 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. 

Your protections from balance billing 

Emergency services 

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 or ambulatory service center 

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. 

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. 

You’re never required to give up your protections from balance billing. You also aren’t required to get care out of network. You can choose a provider or facility in your plan’s network. 

A network provider is prohibited from billing an enrollee for any amount in excess of the allowable amount the health carrier has contracted for with the provider as total payment for the health care service. A network provider is permitted to bill an enrollee the approved co-payment, deductible, or coinsurance. 

A network provider is permitted to bill an enrollee for services not covered by the enrollee's health plan as long as the enrollee agrees in writing in advance before the service is performed to pay for the noncovered service. 

Additional protections when balance billing isn’t allowed 

• 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 the plan 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. 

If you believe you’ve been wrongly billed, you may visit No Surprises Act | CMS for more information about your rights under federal law.