Under PPACA Section 10101, emergency room costs for emergency care are mandated to be covered at the in-network cost-sharing level, whether the emergency room is in or out of network. As always, your PLAN is the place to start (since grandfathered plans are exempt from this provision), but this is primarily for informational purposes, it should help you know where to start.
So, under Section 10101 of the Affordable Care Act, Section 2719A of the PHS Act was changed and provides that IF your plan covers emergency services THEN regardless of whether the emergency room you use is in or out of network you should be covered in one of three ways, depending on which way reimburses THE MOST, the amount your insurance company and emergency rooms have negotiated as their CONTRACTUAL going rate, the amount that insurer uses in calculating Usual and Customary Charges (which is hard for you to find out but will be labeled on your statement), or the amount that would be paid under Medicare for the emergency service.
OK, so what does it appear to seem for our wallets? If you’ve ever gone to an emergency room, you know that there are emergency room charges, these should be covered by your insurer, if your plan comes under the PPACA, at the same rate regardless of your choice of emergency room in terms of the three methods used to calculate reimbursement according to your plan (described above). There is also no pre-approval requirement before using those services.
Start the calculator running…Under most plans you will be responsible for a specific co-payment at the time of getting emergency room services, and co-insurance, which depending on your plan, will leave you paying a certain amount, currently this is usually about 20 percent of the bill.
Again, if you’ve ever gone to an emergency room, you know that you receive bills from emergency room staff and processes and frequently a separate bill from physician practices, which leave you owing money. These amounts are called BALANCE BILLING, the amounts in excess of what insurance pays that YOU are responsible for.
Keep your calculators running under PPACA because it does not appear that there is a solution to the out of network balance billing for which patients will be liable. You’ll want to look into your state’s approach concerning balance billing. It’s worth a call to your insurer if you end up with a bill that is exorbitant, or that you question, since some insurers are actively going after these fees.
For now, it makes no sense to assume or presume that because we have the expanded option to choose and use any emergency room that a trip to the emergency room will still not cost us an arm and a leg after copayment, coinsurance payment and balance billing. Significantly, if you choose a HIGH DEDUCTIBLE HEALTH PLAN, you are frequently responsible for paying that deductible before insurance kicks in.
Conclusion? Read through your plan. Understand what Affordable Care does, which you can find on healthcare.gov “How does the health care law protect me?” Part 6, Doctor Choice and Emergency Room Access which explains that you can “use an out-of-network emergency room without penalty.” The three benefits of the provision are, according to the government site, that prior approval may NOT be required before getting emergency room services, and you cannot be charged higher copayments, and you cannot be charged greater coinsurance rates if you use an out-of-network emergency room.
This does NOT mean that emergency rooms just became more affordable because of the extraordinary amounts that you could end up being charged for copayments, coinsurance (percentage of coverage) and in some cases amounts required to meet your deductible. It also does not currently impact the amount of money that you could have to pay for balance billing, the practice where amounts not covered by insurance are charged to you, especially when the services of other doctors are part of the emergency room experience.
