You dutifully pay your health insurance premiums every month. You're covered for any health-related misfortune that could befall you. Or are you? It's not out of the question that you could seek medical care at an emergency room, only to find out after the fact that you're not covered.
Insurers That Have Refused ER Coverage
United Healthcare made headlines in 2021 for threatening to refuse to cover emergency care, even citing a certain date when the rule would take effect. But United wasn't the first major insurer to do this. Anthem Blue Cross Blue Shield indicated in 2017 that it would not be paying for ER care that it didn't deem to have been an actual emergency based on medical records. This rule would apply to six states: New Hampshire, Georgia, Ohio, Kentucky, Indiana and Missouri.
Then United expressed the same intention to begin on July 1, 2021. As with Anthem, United reserves the right to decide whether the care was actually nonurgent. Costs would not be covered if United decided it was. The insurer then backtracked a little, postponing implementation of the rule until the COVID-19 pandemic is officially behind us.
The American College of Emergency Physicians and the Medical Association of Georgia sued Anthem in Georgia, and Anthem also reversed their decision in 2018.
The Affordable Care Act and Federal Law
According to HealthCare.gov, insurance plans that are compliant with the Affordable Care Act must provide ER coverage, and they must additionally cover out-of-network emergency room care without penalty. Insurers cannot demand higher copays or coinsurance if you visit an ER outside your plan's network, and they can't demand that you get approval before you seek treatment there. The catch lies in whether the care was really for an "emergency."
And this ACA rule applies only to policies that went into effect after March 23, 2010. It's entirely possible that you could find yourself dealing with an unexpected ER bill if your plan is older than this.
Other Insurers That Aren’t ACA-Compliant
Your greatest risk for having to pay for your own ER care lies in not having an ACA-compliant plan. Most short-term insurance plans aren't ACA-compliant, although they do have to clearly acknowledge and indicate this when they're selling policies.
Short-term insurance plans are just what they sound like. They're only intended to cover you for a limited period of time until you can get covered under a "real" health insurance policy. And they rarely, if ever, cover ER visits.
What to Do If You Need Care
Err on the side of caution if you think you need emergency care but you're reluctant to seek it for fear of being nailed with a prohibitive bill that your insurance refuses to cover. Get treatment and sort out the problem later.
The Emergency Medical Treatment and Labor Act of 1986 provides that you can't be denied care if you're uninsured or if you're unable to pay for it out of your own pocket. It requires that insurance companies must pay for that care if you are insured, always assuming that you don't have a short-term plan. Payment must be based on the care you received, not the ultimate diagnosis of your problem.
You have various options if your insurer denies you coverage or reimbursement for care. You can take the matter to the government if you do indeed have an ACA-compliant plan so you should be covered. You can ask the care facility to take up your case with the insurer. They have a stake in getting paid, too, and they're probably much more familiar with the channels to take toward resolution.
Although it might seem grossly unfair, you can try to work out payment arrangements with the care provider as a last resort. You might also look into charity care options.
- ProPublica: He Bought Health Insurance for Emergencies Then He Fell into a $33,601 Trap
- American College of Emergency Physicians: Health Insurers Retroactively Deny ER Coverage
- Patient Advocate Foundation: Uninsured and Facing Emergency? Know Your Rights
- HealthCare.gov: Doctor Choice and Emergency Room Access
- Ars Technica: Biggest Health Insurer Plans to Deny ER Bills If It Doubts You Had an Emergency
- Policygenius: How Emergency Rooms Work