A man falls off the roof while cleaning the gutters. His wife, panic-stricken, hops in the car and speeds down the highway to get him medical attention as quickly as possible while her husband writhes in pain. She thinks his arm is broken, but he also hit his head, so she’s worried about further injuries. The closest hospital is ten minutes away, so she heads there.
Several weeks later, the patient receives a nasty surprise—instead of a bill for a couple hundred dollars, his bill is $5,000-even though he has comprehensive insurance. Looking more carefully at the bill, he realizes his copayments are much higher than he expected.
So what gives?
Many people who have insurance have plans that encourage them to use “in-network” services: Usually consumers must pay more if they use a doctor, health facility, or other provider that is not in their plan’s network.
So if you go to a doctor that is out-of-network, you end up paying a significant amount more.
The problem is that when people need to seek out emergency care services, it’s usually because the condition they are in is so bad, they don’t have the option to put off care any longer. The closest hospital might not be one in your provider network, but when it’s a life or death situation—as emergency room visits often are—patients don’t have the liberty to delay care to find a hospital in-network.
Furthermore, even if you do end up at a hospital that falls within your insurance company’s network, you could run into a whole host of other problems. The doctor who treats you might be in your network, but the anesthesiologist or specialist they bring in might not be –meaning you are responsible for those additional costs.
This, obviously, presents a financial predicament for patients.
Thanks to Affordable Care Act, however, patients will be protected when they run into situations like this. Now, your health plan cannot:
- Require you to get preauthorization for emergency services;
- Make you go through extra administrative hurdles to get your out of network emergency services covered;
- Charge you higher copayments or co-insurance for out-of-network emergency services than it charges you for in-network emergency services; and
- Limit its coverage for out-of-network emergency care more than it would limit its coverage if you received care in-network.
This is a huge step forward for consumer protections. Often, those seeking care in emergency rooms are the most vulnerable, and this takes steps to ensure that patients are protected when they aren’t in a position to decide which hospital to go to or which health care provider to use.