About Emergencies

Emergency Care: Know What Your Health Plan Covers

Provided as a public service by the American College of Emergency Physicians

What kind of health plan do you have?

Medical PlanThe two major categories of health insurance plans are fee-for-service (indemnity) and managed care. Each policy category can differ widely in terms of coverage and cost, and the differences among fee-for-service plans and managed care plans are not clear-cut.

Fee-for-Service Plans
With these plans, bills are sent to the insurance company, which pays a portion (for example, 80 percent) and the patient pays the rest or “co-insurance” (for example, 20 percent), usually after a yearly deductible is met. These kinds of health plans offer the greatest choices of physicians, hospitals, and other health care providers, although they may not pay for preventive care, such as immunizations or well-child care. To receive payment for claims, you may have to complete forms, track receipts, and send them to your insurer. Some health care providers, however, will do this for you. Most fee-for-service plans have a “cap” — the most you will have to pay for medical bills in any one year.

Managed Care Plans 
These health plans negotiate agreements for fees with physicians, hospitals, and other health care providers to give a range of services to plan members at reduced costs. You or your employer pay a fixed monthly fee, you choose among the physicians participating in the plan, and you pay co-payments for physician visits and other services. There may be a deductible, but you generally do not need to complete forms or file paperwork. There are three basic types of managed care plans: preferred provider organizations (PPOs), point-of service (POS) plans, and health maintenance organizations (HMOs).

Types of Managed Care Plans 

  • PPO plans combine some of the cost-control advantages associated with managed care with some of the choices associated with fee-for-service plans. You or your employer will pay a monthly or quarterly premium for coverage of a broad range of medical services. Like an HMO, a PPO charges a co-payment for each office visit, and there is no paperwork to complete. The network of physicians is often much larger than an HMO, and members can refer themselves to physicians outside the approved list, although there is usually a higher co-payment for this service.
  • POS plans allow you to choose primary care physicians to coordinate your care. Although the primary care physician usually makes referrals to other providers in the plan, for a service unavailable within the network, you also can refer yourself outside the plan and still receive some coverage. If a physician refers a patient out of the network, the plan pays all or most of the bill. If you refer yourself to a provider outside the network and the service is covered by the plan, you pay the difference.
  • HMOs are prepaid health plans. The typical HMO provides a broad range of services. You (or your employer) pay a monthly premium for coverage and you pay a co-payment for each office visit. There are no complicated claim forms to complete, and you are usually covered for general physical exams and other types of services that many other insurance plans do not cover. Some HMOs have big medical clinics, with doctors, nurses and therapists on staff. You typically choose a physician from the organization’s roster to coordinate your medical treatment. HMOs tend to provide the least expensive medical coverage and a minimum of paper work. However, your choice of physicians may be more limited.

Emergency Care Coverage

If your health plan includes emergency care coverage, ACEP recommends obtaining answers to the following questions:

Get AnswersWill I have to pay a co-payment or deductible for emergency care?
Many health plans require you to make co-payments (flat fee) or meet a deductible (the amount you have to pay before any health insurance coverage applies). This may include emergency services.

Do I need prior authorization to ensure coverage of emergency medical care?
Some health plans require notification within 24 hours of going to an emergency department, or the expenses will not be covered. Some require you to call your primary care physician first, unless the condition is life threatening. Find out how the term “life threatening” is defined and whether the expenses will be covered if you are unable to contact the health plan right away (e.g., if you are unconscious). 

ACEP continues to advocate for the passage of a national “prudent layperson” standard, which will require health plans to base coverage of emergency care on a patient’s symptoms, not the final diagnosis. For example, if you have chest pains and you suspect it could be a heart attack, but a physician diagnoses indigestion, your insurance should still cover the emergency department visit.

Congress adopted the prudent layperson standard for Medicare and Medicaid beneficiaries, and the President by Executive Order applied the standard to federal government health plans. Medicare and Medicaid managed care plans also may not require prior authorization for emergency medical care. In addition, many states have passed prudent layperson laws; however, millions of people are still exempt, and a national standard is needed to protect all patients.

Can I go to the nearest emergency department, or do I need to go to a specific hospital to ensure coverage?
Find out whether the health plan will cover treatment at certain hospitals, and make sure participating hospitals are located near you. Determine whether the health plan will charge you for going outside the network (because the hospital is closer) in an emergency or when traveling. Also, learn your health plan’s policy on hospital transfers if you go to a hospital not participating in your health plan. ACEP is working toward passage of national legislation that would require your health plan to pay for emergency care received at any hospital.

Who decides what is medically necessary?
In an emergency, your care can not be delayed. However, once your emergency condition is stabilized, the emergency department will coordinate your post stabilization care with your health plan, which sometimes may not agree to cover recommended medical care. 

What can I do if my health plan refuses my claim for emergency care?
If you have a claim problem that is not satisfactorily resolved, file an appeal with your health plan. If you continue to get denied, don’t give up. In some states, the complaint eventually goes before a committee outside the plan (external review), which may evaluate the claim information differently and reverse the denial.

You also may complain to appropriate officials who regulate your health plan. If your plan is self funded by your employer, it is regulated by the U.S. Department of Labor. Otherwise, your state insurance department regulates your health plan and has a complaint procedure that will trigger an investigation into your problem. 

Evaluating Access to Emergency Care through Your Consumer Health Plan: A Checklist for Consumers

ChecklistWhen you or someone in your family needs emergency medical care, the last thing on your mind should be whether your health plan will cover it. The American College of Emergency Physicians says the best way to prepare for a medical emergency is to plan ahead. Reading and understanding the details of your health insurance plan should be part of this process.

Keep in mind that there is a federal law called the Emergency Medical Treatment and Labor Act (EMTALA) that guarantees anyone seeking care at a hospital emergency department—regardless of insurance status or the ability to pay—the right to a medical screening exam and stabilizing treatment for an emergency medical condition. Emergency care cannot be delayed by questions about payment or coordination with a health plan.

Every plan has its own benefits and its own exclusions, limitations, and reductions. It is important not to make assumptions about your coverage. For people choosing a health plan or examining their coverage, ACEP suggests obtaining answers to the following “Checklist for Consumers.”

Many individuals learn about their health plan’s emergency medical benefits when they are in the midst of a medical crisis. ACEP has developed this checklist to help you evaluate your health plan’s emergency medical benefits in advance

1. My health insurance plan has given me written materials that clearly explain what to do if I need emergency care, including instructions on:

  • When to call for an ambulance or 9-1-1 ? Yes ? No ? Don’t Know
  • How to call for an ambulance or 9-1-1 ? Yes ? No ? Don’t Know
  • When to seek emergency care ? Yes ? No ? Don’t Know
  • Where to go for emergency care. ? Yes ? No ? Don’t Know
     

2. My health insurance plan encourages me to call an ambulance or go directly to the emergency department if I think I have an emergency medical condition.

? Yes ? No ? Don’t Know

3. My health insurance plan has given me written material clearly explaining that it will pay for a visit to an emergency department if I have symptoms that most people would consider an emergency (the “prudent layperson” standard) even if it later turns out that my condition was not a true emergency. For example, I have chest pain that I think is a heart attack, but it turns out to be indigestion.

? Yes ? No ? Don’t Know

4. My health insurance plan has given me a telephone number that I can call when my doctor’s office is closed.

? Yes ? No ? Don’t Know

5. When I call this number I am able to speak with a qualified nurse or doctor who can give me advice about my problem and help me decide if I need to go to an emergency department or other health care site for treatment.

? Yes ? No ? Don’t Know

6. My health insurance plan does not require that I call it before I go to an emergency department as a condition for paying for emergency services (i.e., no “preauthorization requirement”).

? Yes ? No ? Don’t Know

7. My health insurance plan does not require the emergency department staff to call it before I am examined to determine if I have a medical emergency. (Federal law requires that a medical screening examination must be performed on every emergency department patient regardless of ability to pay).

? Yes ? No ? Don’t Know

8. After the emergency physician has evaluated me, my health plan has qualified medical professionals readily available to discuss my condition and make arrangements for any further treatment.

? Yes ? No ? Don’t Know

9. My own out of pocket co-payment or deposit is not so high that I’m discouraged from going to an emergency department when I need emergency care.

? Yes ? No ? Don’t Know

10. Hospitals approved by my plan are conveniently located.

? Yes ? No ? Don’t Know

11. I am able to see my regular doctor, as well as any specialists I might need, in a timely manner for urgent and routine medical conditions.

 ? Yes ? No ? Don’t Know

Rating Your Insurance Plan

YES responses to the above questions tend to indicate that your health plan supports appropriate emergency care access. NO responses indicate that there may be a problem. DON’T KNOW responses may indicate that you need to ask your insurance plan additional questions in order to fully understand your coverage.

Remember:

Emergency care cannot be delayed by questions about methods of payment or health insurance coverage.

Health plans should not have barriers to receiving emergency care or discourage you from seeking emergency treatment when you feel it is necessary.

Hospital transfers of patients should be limited only to stabilized patients, or after it has been determined that the medical benefits of a transfer outweigh the possible risks.

 

To obtain more information, check with your health plan’s customer service representative or the agency responsible for regulating health care plans in your state (in most cases this is the Department of Insurance or Department of Corporations).


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