How are emergency services affected under the health reform law?

In an emergency, it is essential that you seek medical help as quickly as possible, no matter where you are. Health plans cannot require prior approval for treatment that you seek in an out-of-network emergency department, under the Patient Protection and Affordable Care Act (PPACA). The PPACA also protects you from incurring financial penalties by seeking care at an out-of-network emergency facility. Health plans cannot charge higher copayments or co-insurance for out-of-network emergency room services than they would for in-network emergency room services. These rights don’t apply to grandfathered health plans (created or bought before March 23, 2010). Check your plan’s materials or ask your employer or benefits administrator to find out if your health plan is grandfathered.

The PPACA does not, however, require health plans to cover amounts that out-of-network providers may "balance bill." In balance billing, a healthcare provider bills you for the difference between the amount your health plan paid the provider and the provider's total fee. The PPACA sets forth minimum payment standards to ensure that a plan or issuer does not pay an unreasonably low amount to an out-of-network emergency service provider who, in turn, could simply balance bill you, the patient. For example, if your emergency room bill is $1,000 and the minimum payment standard for those services is $750, you shouldn't have to pay more than $250 for your emergency room visit.  Some states prohibit certain balance billing practices, such as additional fees when out-of-network specialists are consulted at in-network hospitals. Your policy should explain what your financial responsibilities will be in emergency situations. 

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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.