Will my health insurance cover me in an emergency?

Marcus Pickett

When you need emergency care, chances are you don't have time to double-check your health insurance policy. But someone is going to have to pay for your care. Will it be you or your insurance company?

Here are some guidelines for preventing unexpected trips to the hospital from bringing unexpected bills, along with some provisions in the health care reform law that seek to create a safety net for patients.

The basics

Just as with regular office visits, your health insurance plan will require a co-pay for emergency care. The amount of the co-pay varies by plan. If you are admitted, the deductible usually is waived. Blue Cross Blue Shield of Michigan defines being admitted as having an inpatient hospital stay that lasts more than 24 hours.

Some plans also may include deductibles, the amount you must pay before coverage kicks in. After meeting your deductible, your plan may require you to pay a certain amount of coinsurance. Co-insurance is the amount of your bill that you must pay out of pocket. For example, if your plan has an 80-20 co-insurance system, your insurer will pay 80 percent of the bill, while you pay 20 percent (until a maximum out-of-pocket limit is reached and the insurer pays the remainder of the bill).


Things can get complicated when it comes to provider networks. If you visit a hospital outside your insurer's coverage network, you may have to pay a higher co-pay or a higher co-insurance amount.

Or, according to Kaiser Health News, your plan may require you to get treatments preapproved within a certain time window -- which isn't always possible in an emergency. This most often is the case for those who get coverage through self-insured employers (employers who pay their employees' claims directly instead of providing them with traditional group health coverage through an insurance company).

How health care reform changes things

The health care reform law is best known for the controversial health insurance mandate. But it also includes a few changes for emergency care coverage. All plans that began on Sept. 23, 2010, must meet the following conditions:

  • No higher out-of-network costs: Insurance companies can no longer charge higher co-pays or require the patient to pay more co-insurance for out-of-network hospitals when it comes to emergency care, according to HealthReform.gov.
  • No more approval requirements: No health insurance plan can require prior approval for emergency care at a hospital. Companies that are self-insured also must comply.

Plans that were "grandfathered in" before Sept. 23, 2010, are exempt from these requirements.

Is it really an emergency?

Even with these new requirements, a patient can't visit a hospital for a runny nose and expect everything to be covered. The health care reform law requires that insurers use what's known as the "prudent layperson" standard. In other words, would a "prudent" person consider the visit an emergency? The American College of Emergency Physicians (ACEP) defines a prudent layperson as someone "who possesses an average knowledge of health and medicine."

Keep in mind that whether the situation was truly an emergency depends not on the final diagnosis, but on the prudent layperson's interpretation of the symptoms. For example, if someone goes to the hospital because of chest pain and is simply diagnosed with heartburn, the visit would still have to be covered by her health insurance plan because the pain could have been a symptom of a heart attack.

When making the call on whether to go to the emergency room, the prudent layperson standard may not be much help. The John C. Lincoln Health Network of Phoenix provides a list of conditions that warrant a trip to the ER:

  • Chest pain.
  • Shortness of breath.
  • Stroke symptoms (dizziness, weakness on one side, slurred speech or sudden onset of paralysis).
  • Severe abdominal pain, especially after an injury.
  • Uncontrollable bleeding.
  • Blunt head trauma or penetrating wound to the head.
  • Confusion or loss of consciousness, especially after a head injury.
  • Neck injury.
  • Poisoning or suspected drug overdose, venomous snake bites, scorpion stings or bites from a poisonous spider.
  • Serious burns or cuts.
  • Seizure.
  • Broken bones.