Emergency care can be confusing, especially since the Affordable Care Act (ACA) changed how health insurance plans pay for emergency care. Here are some frequently asked questions and answers about emergency health insurance coverage in Wisconsin to help sort out the confusion.
If you have a health insurance plan that you’ve purchased on or after March 23, 2010, it generally will cover emergency care. Emergency care is one of the ten essential health benefits offered by all ACA-compliant plans. However, if you have a plan that you bought before this date, it is possible that it may not cover emergency care. You will need to check your policy to determine your coverage in the case of a health emergency.
If you have an ACA-compliant plan in Wisconsin, you cannot be charged more for going out-of-network for emergency care. In other words, in emergency circumstances, you may go to the nearest hospital, even if it’s out-of-network. Your insurance company is required to pay if it is truly an emergency (severe life or limb-threatening illness or injury). However, keep in mind that you will still have to pay any copays and coinsurance for emergency care and ambulance transport specified by your health insurance plan. Tests and services, such as lab work and x-rays may not be covered.
No. You do not need prior authorization to go to the ER if you have an ACA-compliant plan. However, as soon as you can, you should call your Primary Care Physician (PCP) and tell the PCP about your emergency. Your PCP will set up any follow-up care you need. This is very important, because if you went to an out-of-network ER, your health insurance company won’t pay for follow-up care that is also out-of-network. Your PCP will see that your follow-up care is appropriate and in-network so that it is covered by your health insurance plan.
If you have an ACA-compliant health plan, covered charges for emergency care will be paid by your health insurance provider, whether in-network or out-of-network. However, you are still liable for the copays or coinsurance of the emergency and follow-up services. Also, if you went to an out-of-network hospital, you may be billed for the difference between what the hospital charged and what your insurance company covered. This price difference will depend on the emergency services required and the type of plan you have. You may also be liable for any follow-up care you had at the out-of-network hospital.
You cannot get emergency health insurance coverage at just any time. By law, you can only buy health insurance during open enrollment or if you qualify for a Special Enrollment Period (SEP). Eligibility for a SEP is based on major life changes such as marriage, divorce, birth or adoption, relocation and other events. Learn more about Special Enrollment Periods.
Still have questions about getting emergency care with a new health insurance plan? Quartz can help. Give us a call at 800.362.3310 to talk with one of our friendly, knowledgeable and helpful customer service representatives.