In the health insurance section of the Q&A advertisement on page A6 of the March 25 edition, there is a question about the definition of an emergency for HMO plan coverage for emergency room treatment. I don’t believe the answer provides a full explanation.
I learned a more detailed explanation during my four years of experience as a volunteer for Pennsylvania’s State Health Insurance Assistance Program (SHIP). We provided free information to the public primarily regarding Medicare and Medicaid, but we learned the basic terminology that applies to all forms of health insurance.
The basic definition of an emergency for health insurance purposes is when a person believes that he or she has a medical condition that could result in death or injury to a body organ that counts, not the final diagnosis by an ER doctor. For example, if a man has chest pain which he believes is due to a heart problem that could result in death due to a heart attack but the ER doctor concludes the pain is due to indigestion and gives that diagnosis, the health insurance company must still classify it as an emergency for billing purposes. That means he will only have to pay an ER visit copay rather than the full cost of ER treatment, which could be six or more times that amount. For HMOs, that applies to both in- and out-of-network care. If the ER visit results in direct admission to a hospital for in-patient treatment, that also must be covered by the HMO both in- and out-of-network.
David Herman
Hempfield