Health Insurance and Emergencies

One of the strongest arguments for getting a health plan is in the case of an emergency. Emergency room visits are increasingly expensive, and having to pay for an ambulance or entry into the ER out-of-pocket can be doubly devastating as the injury or accident itself. The majority of health insurance plans will cover emergency room visits, though as always, it varies based on the state you live in and the company insuring you.

Experiencing an emergency situation is a difficult time requiring you to think on your feet and act quickly. Being knowledgeable of your health insurance policy details in stressful times is especially important. To find out in advance what your health plan covers regarding emergencies, there are several questions you should ask your insurer in advance.


Know Your Plan

A few questions to ask your insurance company or to find out in your schedule of benefits include the following points. They may seem obvious, but internalizing the answer will help when you or a dependent on your plan need emergency care, and save much frustration when paying for the service.


Are emergency room visits covered for a copay or are they subject to the annual deductible?

Depending on your plan, your emergency care will cost you a copayment or a certain percentage of the total service cost. For example, a Coventry One PPO plan with a $2500 deductible in Asheville, NC has a $500 copay for ER visits. This plan waives the amount if the patient is admitted for an overnight evaluation or further hospital stay. However, if the patient has a UnitedHealthOne Saver 80 plan (HSA), they are required to pay 20 percent coinsurance after they meet their deductible, with an additional copay of $500 if they have not been admitted to the hospital.

Does the health plan require pre-authorization for emergency care?

Some health insurance policies require 24 hours of prior notice before you are admitted to an emergency room, otherwise the insurance company may refuse to cover the services. HMOs or POS plans might require you call your primary care doctor before you go to the emergency room, unless a life threatening situation taking place. If you have one of these plans, find out how the term “life threatening” is defined by your policy. Also look into whether the expenses will be covered if you are unable to contact your insurer immediately, for instance, if you are unconscious.

Hospital Selection

Will the plan cover care at the closest emergency department, or does the hospital have to be in-network?

Most PPO plans, even limited ones, offer out-of-network coverage on emergency care – sometimes being the only non-network benefit they cover. Other policies do not cover a visit to a hospital that is not in their provider network. Know your in-network hospitals, and find out if your plan will charge you for going to the nearest facility in an emergency. Ask if your plan covers emergency room visits when you are traveling, out of the state or the country. It is also helpful to find out if how your plan regards hospital transfers if you go to an out-of-network hospital.

Covered Care

Who determines what is medically necessary?

With the urge for hospitals to have a faster turnaround time for their patients’ wellness and cut down on care that is not medically necessary, it is definitely worth consideration to find out what factors decide on your health status. In an emergency, your care will be tended to quickly. The hospital’s job is to stabilize your condition and send you onwards in the most appropriate way. Their recommendation for post-stabilization care may not be covered by your health plan.

What action can I take if my insurer refuses my claim for emergency care?

File an appeal if you have a claims issue that has not been resolved in a fair manner. Start by speaking to your insurance company, and write an appeal detailing your case. If you are denied multiple times, continue to appeal, as you may be able to receive help from outside of the insurer. In some states, the complaint will eventually have an external review, which may evaluate the claim information differently and reverse the denial.

Otherwise, you may register a complaint with the officials who regulate your policy. If you have group coverage, it is regulated by the U.S. Department of Labor. For individual and family coverage, your state insurance department would be the one regulating your health plan and should have a complaint procedure to further investigate your issue.

Click here to find out more about claims.


How to Choose a Plan with Emergency Coverage

Making sure you chose a health plan that covers emergency room visits is a very important consideration when shopping for health insurance. In many instances, the process has been simplified (not having to read every single plan benefit outline available to you) when plans are named “catastrophic.” Catastrophic coverage typically indicates you will be covered in an emergency.

Catastrophic plans are high deductible, low premium plans, with higher costs for routine care – though they ensure you will be covered for emergency and urgent care. These are not the only types of plans offering coverage in case of emergency. Choosing a plan with these specifications is quite simple.

Firstly, you will need to begin the quote process. Select your price range of choice, then view the plan details for those that look affordable. Then, click on the Plan Details to find out more about their emergency coverage. If you want to know more, the plan’s brochure will be attached at the bottom of the Plan Details, which should tell you even more specifics about emergency benefits.

1. Select a plan to review.

2. Click “Show All Plan Details.”

3. Scroll down to Hospital Coverage.

4. Scroll to the bottom and select “Plan Brochure” or “Exclusions” for more information.


Health Plan Checklist for Emergencies

Part of knowing your medical insurance plan’s emergency coverage well is assessing the quality of your plan. How efficiently your health plan allows you access to emergency care, communication, and response are are indicators of a good plan. There should be detailed information regarding what to do in an emergency, and clear explanation of your coverage and limitations. The following is a checklist of important information your plan should include on emergencies. If you cannot find the answer in your policy information or through your insurer’s website, you should speak with your insurer and have any questions resolved.

1. Your plan includes documents that explain in detail how to respond if you require emergency care, with instructions on:

  • When and how to call 911 or request an ambulance
  • When emergency care should be sought
  • Where you should seek emergency care

2. Your plan suggests calling an ambulance or going straight to the emergency department if you feel your health is in an emergency.

3. Your plan has provided a phone number to call when it is past working hours at your physician’s office.

4. When you call this number you are able to speak with a qualified nurse or doctor who can consult with you and help you decide if emergency treatment is appropriate, or whether you should visit another facility.

5. Your health plan provides documents explaining clearly that emergency room visits are covered if you show symptoms that most would consider an emergency, even if it is later discovered that the condition was not actually an emergency. (For instance, if you have chest pains you confuse for a heart attack, which is really indigestion.)

6. Your health plan does not require you to call first for pre-authorization in order to receive coverage for an emergency room visit.

7. Your plan does not ask that the emergency department workers call your insurer to confirm you have an actual emergency, prior to examination. (Federal law mandates that a health exam be performed on every emergency room patient, whether or not they can afford to pay.)

8. Once the emergency room doctor has assessed your case, your plan gives you easy access to health care professionals who will discuss your condition with you, and organize care going forward.

9. Your out-of-pocket expenses are not so costly that you may avoid seeking emergency care if needed.

10. In-network hospitals are in close proximity to your home and workplace.

11. Your plan gives you access to your primary care physician, and any specialists you may require efficiently for urgent and regular medical conditions.