Emergency services coverage
Applies to non-grandfathered group plans
Requirement overview
- All health plans must cover emergency care at out-of-network hospitals at the same copay or coinsurance level as in-network hospitals.
- Health plans may no longer require prior authorization or a referral for emergency services.
- Out-of-network providers may balance bill the member for the amount charged that is above a "reasonable amount." For this reason, it's smart to seek services from an in-network emergency department when available.
- Services provided by out-of-network providers may also apply to a separate out-of-network deductible and out-of-pocket maximum.
Emergency services defined
Medical screenings within the emergency department and treatment required to stabilize a patient.
What Priority Health is doing
- We already cover out-of-network emergency services at the in-network copay and coinsurance levels for all plans.
- We will consult with self-funded employers on the changes that are required.
What you need to do
- Fully funded employers don't have to do anything to comply with this requirement. All plans meet government standards.
- Our sales team will work with self-funded employers to review their emergency services benefit designs and modify them to cover out-of-network services accordingly.
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