Healthcare Reform

Are emergency room visits covered under health insurance plans?

A Answers (1)

  • As a part of the health care reform law, also known as the Patient Protection and Affordable Care Act (PPACA), there are several changes to how emergency room visits are covered.

    Insurers cannot require a prior authorization for emergency services, even if provided by an out-of-network provider.

    Insurers cannot charge higher copayments or coinsurance for emergency services at an out-of-network provider.

    Balance billing is not prohibited, but a "reasonable amount" must be paid before you are responsible for paying the balance of a bill.

      Emergency services must be provided without regard to any other term or condition of the plan or health insurance coverage, other than:
      • the exclusion or coordination of benefits;
      • a permitted affiliation or waiting period; or
      • sharing requirements that apply.
      Insurers may not put a requirement or limitation on benefits for out-of-network emergency services that are more restrictive than those that apply to in-network emergency services.

        Note: the rules for emergency services do not apply to grandfathered plans. However, other federal and state laws related to these patient protections may apply regardless of grandfather status.

        These changes are effective for plan years beginning Sept. 23, 2010.

        For more information on health care reform, visit or

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      Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.
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