NOTICE REGARDING HEALTH CARE PLAN COVERAGE

6/1/2019

This freestanding emergency department (Stapleton Emergency Department ) accepts patients enrolled in the following programs: Colorado Medicaid (Articles 4, 5 and 6 of Title 25.5); Medicare (Title XVIII of the Federal Social Security Act, as amended); the CHIP program (Article 8 of Title 25.5) and a military health plan (10 U.S.C. Section 1071).

The prices listed on this facility’s chargemaster or fee schedule for any given health care service is the maximum charge that any patient will be billed for the service.  The actual price for the health care service may be lower depending on your health insurance benefits and the availability of discounts or financial assistance.

This Facility will charge a facility fee with prices ranging approximately and, on average, from $591 to $11,900. In addition to these fees you will be charged for any testing, supplies, or other services you receive. All physicians providing health care services will bill separately from the Facility for services they provided to you.

The health care provider networks and carriers that this Facility participates with are listed on the attached Exhibit 1.

This Facility and/or a physician providing health care services may not be a participating provider in your health insurance provider network.

If you are covered by health insurance, you are strongly encouraged to consult with your health insurer to determine accurate information about your financial responsibility for a particular health care service provided at this Facility. If you are not covered by health insurance, you are strongly encouraged to contact (866) 475-7872 to discuss payment options and the availability of financial assistance prior to receiving a health care service from this Facility.

The average fee schedule price for the twenty-five most common health care services provided by this Facility are listed on the attached Exhibit 2. The prices listed for each health care service is the average charge that you may be billed for the particular service. The actual price for the health care service may be lower depending on your insurance coverage and the availability of discounts or financial assistance.

Stapleton Emergency Department

Charge DescriptionAverage Charge per Account
Complete blood count lab test $451
Basic panel of 7 or 8 blood tests, with ionized calcium $936
Single or first dose of medication IV $497
Normal saline 1000ml $401
Tubing used for IV $27
Each additional hour of IV fluid hydration $638
30mg injection of Ketorolac, a non-steroid anti-inflammatory medication $200
External recording of electrical activity of heart $740
20 gauge IV $12
Urine test conducted via machine with micro $272
Urine pregnancy test $167
Injection of medication or vaccine given intramuscular or subcutaneous $381
4mg vial of Ondansetron, used to prevent nausea and vomiting $364
ED PROC CAT 1 $1,082
Ibuprofen 600 mg tablet $1
ED PROC CAT 2 $1,721
Blood test for heart muscle $1,006
Each additional hour of IV fluid hydration $570
Chest x-ray with two views $536
Low osmolar contrast material used in diagnostic radiology $259
Liquid ibuprofen 20mg/ml taken orally $2
20mg tablet corticosteroid used to treat inflammation of skin, joint, lungs and other organs taken orally $20
Inhalation treatment of airway obstruction $733
Administration of a nebulizer $3
Complete panel of 14 blood tests $1,125

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Contracted Plans

PlanCommercial Group and IndividualManaged MedicareManaged Medicaid
AETNA (Inc. Coventry and FirstHealth) All Networks All Networks N/A
Anthem BCBS All Networks All Networks N/A
BrightHealth All Networks (Emergency Only) Not participating N/A
CIGNA All Networks All Networks N/A
Clear Spring N/A All Networks N/A
Colorado Access N/A N/A All Networks
Friday Health Plan Not Participating N/A N/A
Humana Not participating All Networks N/A
InnoVage N/A All Networks N/A
Kaiser All Networks (All FSED Locations only) All Networks and locations N/A
Multiplan/PHCS All Hospital Networks (excluding physician only networks) N/A N/A
Mutual of Omaha N/A All Networks N/A
OSCAR All Networks N/A N/A
Rocky Mountain Health Plan All Networks All Networks All Networks
UnitedHealthcare All Networks (except Colorado Doctors Plan) All Networks N/A