How HMO Works – Emergency Room Coverage

How HMO Works – Emergency Room Coverage

Your HMO coverage not only covers preventive care - it helps you in situations that may not be so preventable. Unexpected mishaps happen to everyone and can be overwhelming for the most put-together person. Let’s be for real, there is never a good time to break an arm, fracture a rib or have chest pains. Having health insurance can help you prepare and breathe a little easier when an unexpected health condition or accident happens.

Emergency room visits cost more than a visit to your Primary Care Physician (PCP), so you want to be absolutely sure you need to go to the emergency room. Health conditions like stomach aches, fevers or minor burns can be handled by making an appointment with your Primary Care Physician. If you’re not sure, you can call your PCP for advice on how you should treat your health condition. They can help you decide if you need to come into the doctor’s office or go to a retail clinic, urgent care facility or emergency room.

If you believe your health issue is life-threatening, don’t wait! Call 911 or go to the nearest hospital emergency room. The emergency room will reach out to us to approve care. You or a family member should call your PCP within 72 hours if you are admitted to the hospital from the ER. If you aren’t admitted, you will need to call your doctor soon after you leave the hospital to schedule follow-up care.

Here are a few things to remember for emergencies:

Questions to ask before you’re admitted to the hospital
It’s important to know that your HMO coverage for your emergency room visit ends when you are admitted to the hospital. If you are admitted to a hospital that is not in your network of providers you will be charged the full cost of your treatment and stay. That’s why it is important to contact your PCP if you are being admitted, so that they can ensure you are referred to a facility that is in your network.

Ask these questions to help you stay informed on cost and HMO coverage:

  • Does this facility accept my insurance plan?
  • Are lab and other tests included in my coverage, and how much will I have to pay?
  • What medical care does the facility provide?
  • Is there a separate charge for any and all other treatments I may receive?
  • How much will this treatment cost?
  • What practitioner is on duty now – an HMO doctor, a nurse?
  • Will treatment be covered by my insurance or how much will I have to pay?

Know what your HMO plan covers

  • The most important thing to worry about in a life threatening emergency is getting to your nearest emergency room. For some plans, the cost for a trip to an in-network emergency room and an out-of-network emergency room are about the same.
  • In many cases, if you are admitted to a hospital that is not in-network for your plan your stay will not be covered. Once you are well enough, the out-of-network hospital will transfer you to an in-network hospital for ongoing inpatient care.
  • The copay for visiting the emergency room is higher than the copay for visiting your PCP. Emergency room copays can cost you hundreds of dollars. Make sure to get a clear understanding of your coverage benefits.

Be prepared

  • Take the steps above to know what your HMO plan covers. Your policy kit includes a summary of benefits that your plan covers and what it costs. 
  • Locate your nearest hospital emergency room, retail clinic and urgent care facility. 
  • Know where to find your membership ID card. Keep your ID Card in a place that is easy to find at all times, like your wallet. Let someone you trust know where to find your card in case of an emergency.

There is a lot to consider when deciding where you should go for care. We are here to help you understand all your options for care.

Not all benefits are offered by all health plans. Make sure you know what you are covered for!

Disclaimer: The information provided in this document is based on current information, should not be considered comprehensive and should not be relied upon for benefit decisions. It should not be considered legal or tax advice.