Health Insurance 101: How Are Emergency Services Covered?

Insurance is the last thing you want to think about during a medical emergency.

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During a life-threatening medical emergency, the last thing you want to do is stop and skim through your health insurance plan. Different plans offer different degrees of coverage for emergency services. Most plans allow you to see an out-of-network provider for emergency care without penalty, but there are still some that may require you to use an in-network emergency department to receive full coverage.

The point is, it’s a good idea to be familiar with your plan’s emergency coverage before an emergency happens. That way, you’ll know exactly what to do during an emergency without fretting about your insurance or worrying about unexpected costs.

Using Health Insurance for Emergency Services

Your health insurance plan should offer a brochure that gives details for emergency coverage. This brochure should provide a chart about what you can expect to pay for a variety of services, including visits to urgent care or emergency rooms. Every plan varies, so you should be familiar with the details each time you change plans.

On this chart for emergency room care, you will likely see one of the following:

  • A copay: This means you will pay a set fee to visit the emergency room, such as $300. Plans with higher premiums (monthly fees) tend to charge lower copays for emergency room care.
  • A coinsurance: This means you’ll pay a set percentage of the emergency room bill, such as 40 percent. Learn more about the difference between copays and coinsurances here.
  • Both a copay and coinsurance: For example, you might pay a $200 copay as well as 25 percent of the total bill.
  • Your deductible, then coinsurance: Here’s where it gets a little complicated. This means you may have to pay the full price for emergency room care—unless you have already met your deductible. That’s the amount you pay for medical expenses in a policy year before insurance kicks in. If you’ve already met your deductible that year, you would then only pay the coinsurance for this ER visit.

Understanding Your Options

As you can see, emergency room care usually costs more than visits to urgent care or your primary care doctor. That’s why it’s helpful to save the ER for life-threatening issues. This includes heart attacks, strokes, severe injuries or burns, and loss of consciousness.

You’ll save money by using urgent care facilities for non-life-threatening issues. For example, you might need antibiotics for strep throat, but your primary care doctor doesn’t have any available appointments for a few weeks. That’s a good time to visit urgent care. Other examples include a minor cut that needs stitches, small rashes, minor broken bones, and minor burns.

If you’re not sure which is the right facility for your health issue, you may be able to call your primary care doctor. Some may even be available off hours. They can help provide guidance about where you should go. If you think you don’t have time to call your doctor, that’s probably a sign that you should go to the ER.

Want more information about emergency care coverage? Call an insurance representative. They can help provide details about emergency coverage for your specific plan, or help you compare the coverage of different plans.