A Basic Explanation

If your spouse suddenly has chest pains and trouble breathing, you shouldn’t have to stress about whether a trip to the ER will break the bank. That’s why the Affordable Care Act offers some protection against high medical bills in the event of an emergency.

Anytime you or a loved one has a medical situation that any reasonable person would believe could lead to serious disability or death if not immediately treated, you can head to the hospital without getting permission, or preauthorization, from your insurance company. And you’ll still be covered if the nearest hospital is out of network.

Expert Advice About Emergency Care

When you buy an ACA health plan, your basic emergency room care will be covered, even if a hospital is out of network. When you’re enrolled in one of the metal tier plans sold in any of the ACA marketplaces, you won’t be charged higher copayments or coinsurance for any out-of-network emergency services. When it’s an emergency, marketplace plans (as well as most other health plans) also won’t require you to get approval from your insurance carrier first before heading to the ER. And if you’re admitted to the hospital, many plans will forgive emergency care copays altogether.

However, that doesn’t necessarily mean your ER visit will be completely covered. Here’s where it can get a little tricky. Even after you pay your copays or coinsurance, out-of-network providers can still bill you for the unpaid balance of charges that are above and beyond what your insurance company covered. This is called balance billing. And those numbers can add up. Keep in mind that the law’s newest limits on consumers’ out-of-pocket healthcare costs— $6,600 for an individual and $13,200 for a family in 2015 — apply only to in-network care.

Once your condition (or that of a family member) is stabilized, you’ll want your doctors to coordinate with your insurance company on continuing medical care with providers in your plan’s network. This is to avoid racking up huge medical expenses.

Remember, don’t use the ER for anything other than a true emergency. It’s rare for a carrier to reject a claim for an accident or illness that’s clearly life-threatening. But if you visit the ER for a medical issue that could be resolved by your primary care physician or at an urgent care facility, there’s a good chance you’ll be billed for the entire cost of your visit.

What else you need to know

Read through your summary of benefits carefully. Some of the health plans you can buy outside the ACA marketplaces, particularly those offered by an employer, don’t necessarily follow the guidelines outlined by the ACA. For example, some employer plans may require approval for emergency care within the first 24 hours.

None of us like to think about medical emergencies, but it’s smart to be prepared. You don’t want to be left scrambling at a time when every second counts.

Know where your closest emergency room is in case you or someone in your family has a life-threatening medical issue. That’s the best place to get the care that can save life and limb.

However, if you need immediate medical attention for something less serious, visit an urgent care facility instead. While not necessarily equipped to handle life-or-death situations, urgent care centers can often treat immediate medical needs faster, and cheaper, than a trip to the ER.