Insurance Tips

Provided By Evangelical Community Hospital and The American College of Emergency Physicians

When choosing which health insurance is best for your family or business, you need to consider more than the cost and the choice of doctors. It's also important for you to understand what kind of emergency coverage your insurance plan provides.

In order to evaluate the coverage you receive, the American College of Emergency Physicians (ACEP) suggests that you check with your insurance company or your employer's benefit department to find the answers to the questions presented here.

Keep in mind that although your plan can deny payment, they cannot prevent you from obtaining emergency care. Under federal law, you cannot be refused treatment for a true emergency because of lack of insurance or inability to pay.

In addition to emergency coverage, you should examine how your plan handles hospitalization, co-pays, deductibles and pre-existing conditions.

Common Questions:

Other Tips and Questions to Consider:

Is a primary care doctor available evenings or weekends to treat minor conditions?

Check to see if there are arrangements for after-hour care.

Does your plan pay for emergency department screening exams?

Emergency departments are required by federal law to perform an exam to determine if you have an emergency condition. You should find out if this screening exam is covered even if payment for treatment is denied.

Will the emergency physician have to call my plan for authorization before treating me or will I be responsible for that call?

Will the emergency physician be able to discuss your case with your doctor, instead of an administrator?

How is coverage for emergency visits determined?

Does your plan review your case after you have been treated and pay for your visit only if you were diagnosed with an emergency condition? Are you covered for emergency visits based on the severity of your symptoms? Check to see if your plan uses an "approved list" of emergency conditions.

Is there a separate deductible or co-payment for emergency visits?

If so, does it apply only to the services that are determined to be "non-emergencies," or to all emergency visits? What is the cost?

If you are admitted to a non-participating hospital for an emergency, will you have to be transferred later?

If you do need to be transferred, who will decide when it is safe for you to be transported? Does your plan cover transport from the scene to the hospital? Does it cover transport from hospital to hospital or other healthcare facilities?

Does the plan require an observation period before admission to a hospital for certain diagnoses?

Check to see if there are there is a required observation period for your diagnosis.

Are there restrictions on follow-up of emergencies with specialists or emergency facilities?

Check to see if there are there are limitations on follow-up care after emergencies and with certain specialists, locations, etc. Follow-up care is most often not a return visit to the emergency room.

What are the facilities and coverage for mental health emergencies?

Are mental health emergencies covered and to what extent? Are there restrictions on where you can go.

What to do if you have a problem?

If your plan denies payment of legitimate emergency services, you can appeal your plan's decision. Your plan should not discourage you from calling an ambulance or going to an emergency department when you feel it's necessary. Contact the plan's grievance system if you receive a less than appropriate response and notify the agency that licenses insurance plans in your state.