In Ohio, the law says that, in an emergency, one should go to the nearest facility, regardless of whether or not it’s in-network. In fact, the law says that one’s insurance carrier must cover the treatment in such a case as if it was in-network, even if it’s not.
“Emergency” is defined under the “prudent layperson” rule: “a prudent layperson is someone with average knowledge of health and medicine.” In other words, even a rocket scientist could be a prudent layperson, as could I.
The definition continues:
“An emergency is a condition of such strong pain and severe symptoms that a prudent layperson could reasonably expect that a lack of immediate attention would
- Place the person’s health in serious risk;
- In the case of pregnancy, place the baby’s health in serious risk;
- Cause serious damage to bodily functions; or
- Cause serious damage to an organ or other body part."
In such a case, one’s “managed care plan [HMO, PPO, etc] must pay your medical bills for that emergency, no matter where you receive the services…In an emergency, you should go to the nearest hospital, even if " it’s out of network.
Pretty straightforward: If there’s an emergency, you go to the nearest facility, get treated, and pay as if you’re in-network. On the one hand, it doesn’t mean the care is “free:” you might still have deductibles, co-pays, etc. But you’re not subject to out-of-network penalties, either.
Or so I’ve understood for lo these many years. But I received an email today from a carrier, which shall remain anonymous (for now), which seems to fly in the face of long-established health care procedure and knowledge. Because this carrier has been unsuccessful in coming to terms with several local hospitals, it has decided to punish its own customers. To wit:
“When a member receives emergency care at an non-contracted hospital, [Carrier X] will pay for the services at the in-network level subject to a maximum allowable amount…If a non-contracted hospital charges the member more than this amount, the member will be responsible for the difference.”
[note: I am deliberately withholding the url until the matter is resolved]
See the problem here? Me, too.
One thing that I have never been called is a shrinking violet (or shrinking anything, really). So I just had a nice conversation with the helpful folks at the Department of Insurance, who were also quite concerned. I've forwarded this email to them so that they can look into the matter with a bit more “ammo.”
I’ll let you know how things turn out.