The Affordable Care Act requires insurance companies to pay for emergency services as an in-network benefit even if you receive care from a non-network provider, but what’s the definition of a medical emergency? Well, it may differ slightly from one insurance company to another, but here’s the definition found in the policy for a Blue Cross Blue Shield of Texas plan:
Emergency care is defined as health care services provided in a participating or nonparticipating hospital emergency facility, freestanding emergency medical care facility, or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in placing the patient’s health in serious jeopardy, cause serious impairment to bodily function, cause serious dysfunction of any organ or part of the body, cause serious disfigurement or, in the case of a pregnant woman, cause serious jeopardy to the health of the fetus.
In a medical emergency, seek care immediately. Present your ID card to the hospital emergency room or comparable facility. You or a family member should call your PCP within 48 hours or as soon as possible after receiving emergency care. This call is important so that your PCP can coordinate or provide any follow-up care required as a result of a medical emergency.