Where in the ACA is the section that talks about emergency visits to hospitals and when an out-of-network doctor provides care to a patient. I recently had emergency surgery and i was provided care by an a out-of-network doctor. I want to appeal my health insurance’s decision not to pay this doctor because the doctor is out-of-network.


Answer

Out-of-network emergency care is covered under all insurance plans sold after March 23rd, 2010 as part of Ten Essential Benefits under the Affordable Care Act.

Insurance plans can't require higher copayments or coinsurance if you get emergency care out-of-network and they cannot require prior approval either. All non-emergency care must be done in-network to be covered and may require prior approval.

If your insurer is trying to bill you for the care you may have to appeal their decision.

Grandfathered plans bought before March 23, 2010 may not follow this same rule. Short term health insurance and some other coverage types may also not follow this rule.

If you get any care that is not strictly emergency care, out-of-network rates may apply. So always be very careful with this and make sure you are communicating with your insurance provider so you don't get blindsided by extra costs. Some plans will have a separate out-of-pocket maximum and deductible, so keep that in mind too.

This information can be verified at HealthCare.Gov or can be found in Sec. 1302. of the Patient Protection and Affordable Care Act. You may want to check out our page on Ten Essential benefits for further reading.

Rate and Comment on the Answer

Your email address will not be published. Required fields are marked *

1 2 3 4 5

Betty Marano on

I received an email from a friend which states that when one is seen in a hospital emergency room and is then admitted for further observation, that admission is not covered by Obamacare and all costs are charged to the patient. Is this true?

ObamaCareFacts.com on

No exactly, the rules are actually a little complex. Generally emergency is covered, but the rest must be coordinated with the insurer. If the stay is essential then it would be covered with cost sharing (but again, this needs confirmation from the insurer ASAP.. not just the doctor).

Sylvia on

What does the words “Generally” and “the rest” mean in your message?

ObamaCareFacts.com on

Generally means “check with your insurer, don’t go get care based on this commment alone” and “the rest” means non-emergency services (like if you wake up in a hospital and then order an X-ray and stay an extra day without checking with your insurer).

This is to say, “the rules are clear” about emergencies, but the loopholes and details are way too complex to not coordinate with an insurer in an instance where one is needing out-of-network emergency care.

Specifically, we don’t want to come across as giving actionable advice on emergency room visits as that is not the intent or scope of the website. The insurer is always the right entity to contact (unless it is an emergency, then the first contact is a public hospital or 911).

Josh on

This is extremely misleading. Out-of-network emergency visits do not count toward your deductible or maximum out-of-pocket. Additionally, insurance companies and hospitals work out special rates they can charge. These special rates do not apply to out of network hospitals.

For example, say your remaining deductible is $0 for the year and your maximum out of pocket is $0. Also say that an emergency room visit at the hospital in Grayling, MI normally costs $2500 to “in-network” insurance companies. What you’ll find is that this same visit costs $4500 to “out-of-network” insurance companies. Additionally, this $4500 is completely ignored by your deductible and maximum out of pocket expenses.

So at first, you may think this visit would be free (or mostly covered). But you’d be wrong.
At second, you’d think it may only cost $2500, but you’d be wrong.
Lastly, you’ll find out you’re paying bill for $4500 and wonder what the insurance is actually doing.

ObamaCareFacts.com on

This is part of the law and can be verified here: https://www.healthcare.gov/health-care-law-protections/doctor-choice-emergency-room-access/ and http://www.hhs.gov/healthcare/about-the-law/er-access-and-doctor-choice/index.html

Access to out-of-network emergency room services: Insurance plans can’t require higher copayments or coinsurance if you get emergency care from an out-of-network hospital. They also can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.

Health plans cannot require:

Higher copayments or co-insurance for out-of-network emergency room services
Approval before seeking emergency room services from a provider or hospital outside your plan’s network

So with this said, if you are getting charged thousands of dollars. APPEAL, APPEAL, APPEAL: https://www.healthcare.gov/appeal-insurance-company-decision/appeals/

MIchael on

I recently had emergency surgery at a local (California) in-network hospital. I was admitted via the emergency room and had surgery the following morning. Apparently, the operating surgeon that the hospital assigned to me is not covered in my health plan (Silver PPO coverage through Anthem Blue Cross).

I read somewhere that in California there are specific rights regarding non-covered emergency procedures, but I can’t seem to find the website again. Do I have any options regarding payment assistance or relief? Any information is greatly appreciated, thank you!

Michael

Jane Doe on

In California you can contact the Department of Managed Health Care at http://www.dmhc.ca.gov/ (1-888-466- 2219) for assistance with appeals and payment issues.

Angie on

If you go to emergency room and you get a surprise bill to pay for the emergency room be cause it was apparently out of network. How is that make sense if you are going to the closest hospitals. Why should I be paying out of pocket for emergency room if it life or death. This is ridiculous.

ObamaCareFacts.com on

A true emergency visit shouldn’t be subject to out-of-network billing. I would appeal this to the insurer. Are rules strict, yes, but a true emergency is in-network as I understand it.

Alex on

They don’t actually cover emergency room visits to out of network hospitals for emergency care. They only allow the deductible and cover whatever fee they would usually contract. In the case of my bronze plan which is still very expensive, they only have a deductible and cover nothing more with in network hospitals as in network hospitals are required to write off the rest of the expenses.

As a hospital you can imagine they don’t want to sign on with this plan. So when I’m lying on the ground unconscious and go to the nearest hospital, it’s a gamble on whether or not they are in network. If they are out of network the hospital can bill the patient whatever they want and the insurance company can tell you to go kick rocks.

I had a 5,500 deductible but somehow I’m required to pay $10,000 and only 3,500 of that went to my deductible. I appealed, I contacted the office of insurance and everyone either doesn’t care or are certifiably retarded.

It’s what happened and I don’t know why I pay $200/month since it essentially covers nothing in an emergency.

Failed plan, it’s a scam. Blue cross blue shield bronze pathway. Might just stop paying you and tell Obama to kick rocks since he did the same to me.

ObamaCareFacts.com on

Right, it is covered as if it were in-network when you need out-of-network in an emergency right? You can appeal if you feel the insurer isn’t being fair. I’ll have to research the specifics of this more to make sure i’m not missing something.

D. Sanson on

Even though the plan must pay emergency services at the in-network benefit level (and in-network cost sharing amounts), the out-of-network provider is permitted to “balance bill” the member for the difference between a provider’s charge and what the plan paid. The plan will pay the greatest of:
– the median of the amount negotiated with in-network providers;
– the usual and customary amount;
– the amount that would be paid under Medicare.

Despite which method the plan uses to reimburse, the out-of-network provider is permitted to bill the member for the difference.

ObamaCareFacts.com on

Good insight, thank you.

Chris Pflum on

I am receiving out-of-network bills for emergency services from a hospital that has been paid the in-network rate by me and my insurer. The hospital claims that I must pay the full rate, which is approximately four times the network rate, because they did not have a contract with my insurer. I replied that under the affordable care act, my emergency care must be provided at the network rate regardless of whether or not the hospital and insurer have a contract. The hospital did not reply, but gave my account to a collection agency that constantly threatens legal action. Please advise whether the in-network rate for emergency services applies to both insurers and hospitals.

E Gold MD on

Unfortunately the hospital is right. The in/out of network differences apply to what your insurance company has to pay for services, how to apply your use of services to the deductible and max OOP, and what you plan’s *contracted* hospitals have to accept in payment.

This issue has hit consumers for years and has nothing to do with ObamaCare. The other elephant in the room is balance billing, which is probably the underlying reason why your bills are so high. All you can hope to do is negotiate directly with the providers for a lower rate. Try a less confrontational approach, and good luck.

ObamaCareFacts.com on

Good information, thanks.

Megan on

I had to go to the er in February and am now stuck with a 5 thousand dollar bill that my insurance decided not to cover because I went to a banner hospital instead of abrazo. It was a true emergency and now I have a bill that is more than my car. Can I appeal it if I since cancelled my healthcare because I lost my job and could no longer afford it?

Michelle Peat on

I went to Urgent Care on a Saturday in July. The facility was in network, benefits were denied. Per Anthem, I must go to the ER for emergent care.

Chris Pflum on

My insurer did not have a contract with the hospital where I had emergency services, but a network rate was negotiated and paid by my insurer and me. Now the hospital is trying to collect from me, the difference between the network rate and the full rate. My insurer claims that the hospital has been paid the applicable fee and my state’s insurance commission agrees. Please advise whether the network rate applies to both the amount that a insurer must pay and amount that the hospital must accept.

Chris Pflum on

I posted this question nearly a month ago and ObamaCareFact has not responded. Does that mean that the Affordable Care Act allows hospitals to gouge patients for whatever they cannot get from insurers (i.e. the network rate). Medicare prohibits this so-called demand for a “balance payment”.

Susan F on

Yes, this is EXACTLY what it means. Whether thr provider can balance bill the patient is determined by state law. You need to check with your state insurance agency. Texas allows balance billing er care by out of network hospitals & ambulances, but does offer some protection against out of network providers that are providing care at in-network hospitals.

Priscilla Bible on

Need some guidance. My one year old suffered from a complex seizure lasting over and hour, with no previous history of seizure disorders. Called 911 and was transported to a non network provider. We had no choice in the matter. Florida blue is denying the claim due to services being out of network. I’ve already appealed and got denied. The 3 day stay is totaling over 29k . How is this ok? It cannot be ok to deny payment for emergent services . Help!

ObamaCareFacts.com on

So a true emergency service should be covered (although its not for me to say this, its for the insurer, it should be due to the way essential benefits work under the law), you can, should, and must appeal this (first do an internal and then external if needed).

Joe on

The text of the ACA says “Any cost-sharing requirement other than a copayment or coinsurance requirement (such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services provided out of network if the cost-sharing requirement generally applies to out-of-network benefits.”

That means PPO members are subject to out-of-network deductibles and out-of-pocket limits for emergency services.

Source: https://www.law.cornell.edu/cfr/text/45/156.130

§ 156.130(g):
Coverage of emergency department services.
(2) If such services are provided out-of-network, cost-sharing must be limited as provided in § 147.138(b)(3) of this subchapter.

§ 147.138(b)(3):
(ii)Other cost sharing. Any cost-sharing requirement other than a copayment or coinsurance requirement (such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services provided out of network if the cost-sharing requirement generally applies to out-of-network benefits.

Johnny Salami on

The answer states that they cannot require higher copayment or co-insurance for emergency services. Is that the rate of co-insurance, or is it that the amount of co-insurance you pay should not be higher? It seems the insurance companies may only pay the greater of 1) the amount they would have paid their contracted provider 2) Medicare allowance or 3) Usual/Customary. Often this amount is a fraction of the total billed amount of the non-participating emergency services provider, who will likely balance bill for the difference. So, it is my understanding that the patients real expenses can be much greater than of they had gone in-network for emergency treatment.

This answer leads an individual to believe that they are somehow held harmless for expenses greater than what they would have paid if they received emergency services in-network.