Navigating and understanding the Affordable Care Act’s effects on the world of insurance compliance can be confusing, but when it comes to determining whether your emergency health care will be covered, the issue can be summarized into relatively simple language:
The Affordable Care Act treats emergency health care as an essential health care benefit and it requires insurers to do the same – that means insurance companies must provide coverage for any emergency visit as if it were an in-network visit.
In other words, you have the right to use any emergency room without penalty. Insurance plans can’t require higher copayments or coinsurance if the emergency care occurs at an out-of-network emergency room.
You also don’t need prior approval before getting emergency room services – just head straight for Elite Care or the nearest emergency room. Insurers can’t require you to get prior approval for an emergency room outside your plan’s network.
How is an emergency visit defined?
The Emergency Medical Treatment & Labor Act (EMTALA) defines an emergency medical condition as “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.”
For example, a pregnant woman with an emergency condition must be treated until delivery is complete, unless a transfer under the statute is appropriate.
More on the Affordable Care Act
Visit www.healthcare.gov for more information on the Affordable Care Act.