Emergency Services and the Affordable Care Act

Posted on: Wednesday, October 9, 2013

Visits to trauma centers, ambulance calls, and all other emergency medical services are fully covered and protected by the Affordable Care Act, but that is only part of the story. 

The typical health care plan encourages enrollees to use service providers in their network. These plans usually require their members to pay more if they use a doctor, hospital or other provider that is not in the network. When there is a medical emergency, however, treatment may not always be possible in-network. The ACA has addressed this situation by prohibiting health plans from:

  • Requiring members to get a pre-authorization for emergency services
  • Charging higher co-pays for out-of-network emergency services 
  • Limiting coverage for out-of-network emergency care 

While the ACA prevents health care network providers from charging more for emergency services, it does not limit the ability of out-of-network providers to bill you for the difference between what your health plan pays for the service and their established fees for the same service. It is also important to note that this out-of-network provider is entitled to bill you for any charges not covered by your health provider. 

Nevertheless, the ACA sets some minimum standards for what health plans must pay out-of-network providers. Your health plan is required to pay the greatest of these three amounts:

  • The amount it pays in-network providers
  • A payment based on the same methods the plan uses to pay other out-of-network services (for example, a percentage of usual and customary fees charged by other providers in your area)
  • The amount Medicare would pay for that medical service

In many municipalities, EMS providers are town employees. In theory, cities and towns which manage EMS services should see an increase in revenue, since more people will have coverage, and their services cannot be denied. While only time will tell, this could mean more money for equipment and improved EMS facilities.

Do you have questions regarding the Affordable Care Act? We are ready to help. Please call us at 1-877-214-2969.

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