If you are privately insured in Wisconsin, it’s important to know what type of coverage you have when traveling. All private health plans that comply with the Affordable Care Act (ACA) must provide emergency care coverage, even when you're traveling. That begs the question “What is an emergency medical condition?”
The definition in the Affordable Care Act regulations states: “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.”1
Some examples of emergencies include –
If you have a problem, but don’t think it’s an emergency (such as the flu or a sprained ankle), you should call your doctor’s office. Most doctors’ offices have 24-hour call coverage and they will advise you. Keep in mind that many private health insurance companies require you to call them before you go to an urgent care clinic that is out-of-network. Be sure to check your policy.
Yes – ACA-compliant health plans cover services provided in the Emergency Room and during the ambulance transport to the hospital. Private health insurance companies cannot charge you more in copayments or coinsurance for going out-of-network or for not having Prior Authorization in the case of a health emergency. However, you will have to pay any copayment or coinsurance amounts specified by your health plan for the ER visit and ambulance transport. You may be charged for lab work, x-rays and other services that are not part of emergency care.
It’s also very important to note that once the emergency care is delivered, out-of-network follow-up care may not be covered by your private health insurance company. For example, let’s say you’re traveling and experience severe chest pains and go to the emergency room. The diagnosis is not a heart attack but rather, kidney stones. Most private health insurance companies will pay for the emergency diagnosis and care and then will require you to go to an in-network clinic to treat the kidney stone problem. If you choose to get the care out-of-network instead of returning to an in-network provider, you can expect to pay the full cost of the follow-up care.
Sometimes people are surprised when they receive emergency care out-of-network and then get a bill from the hospital where they received the care. The bill is for costs not covered by your private health insurance company. This is called “balance billing.” “Balance billing” means that the hospital that gave you emergency care was paid by your private health plan, but that payment did not fully cover the costs of the care. In this case, you will be billed for the balance. This process is allowed under the ACA but may not be allowed under state law.
If you are often on the road, you should consider a private Preferred Provider Organization (PPO) health plan. PPOs can offer a nationwide network, which increases your ability to see a doctor who is in-network, no matter where you are in Wisconsin or the United States.
Overseas travelers should find a private health plan designed for their needs. Some private health insurance companies in Wisconsin may not offer plans that cover health care provided outside of the United States. Be sure to check your policy to be sure.
Unity can help. Give our knowledgeable and helpful customer service representatives a call at 800.362.3310.
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