How HMO Works – Emergency Room Coverage

How HMO Works – Emergency Room Coverage

Your HMO coverage not only covers preventive care - it helps you in situations that may not be so avoidable. Unexpected accidents happen to everyone and can be overwhelming for the most put-together person. Let’s be real, there is never a good time to break an arm, fracture a rib or have chest pains. Having health insurance can help you prepare and breathe a little easier when an unexpected health condition or misfortune happens.

First of all, emergency room visits cost more than a visit to your Primary Care Physician (PCP), so you want to be absolutely positive you need to go to the emergency room. If you’re not sure, you can call your PCP for advice on how you should treat your health condition. They can help you decide if you need to come into the doctor’s office or go to the emergency room. Health conditions like stomach aches, fevers or minor burns can be handled by making an appointment with your Primary Care Physician.

Emergency RoomIf you believe your health issue is life-threatening, don’t wait! Call 911, or go to the nearest hospital emergency room. The emergency room will then reach out to us to approve your care. If you are admitted to the hospital from the ER, you or a family member should call your PCP within 72 hours. Involving your PCP as soon as possible can help you get the care you need. Even if you aren’t admitted, you will still need to call your doctor soon after you leave the hospital to schedule follow-up care.

What to remember in case of emergency:
Be prepared

  • Know what your HMO plan covers. Your policy kit includes a summary of your costs and coverage. Your benefits can be found in Blue Access for MembersSM. You have 24/7 access to details about your plan’s benefits, claims, information and printable temporary ID cards.
  • Know where to find your membership ID card. Keep your membership ID card in a place that is easy to find at all times, like your wallet. Let someone whom you trust know where to find your card in case of an emergency.
  • Locate your nearest hospital emergency room or retail clinic Use the Blue Cross and Blue Shield of Illinois Provider Finder tool to locate your neighborhood in-network health care providers.

Know what your HMO plan covers

  • The most important thing to worry about in a life threatening emergency situation is getting yourself to the nearest emergency room. For some plans, the cost for a trip to an in-network emergency room and an out-of-network emergency room are about the same.
  • Remember that the copay for visiting the emergency room is considerably higher than the copay for visiting your PCP. Emergency room copays can cost you hundreds of dollars. To get a clear understanding of your coverage benefits, you can review your policy kit, check your plan details in Blue Access for Members or call the number on the back of your membership ID card.
  • In many cases, if you’re admitted to a hospital that is not in-network for your plan your stay will not be covered. This is why, if possible, you want to contact your PCP prior to being admitted so you can be referred to a location that is in-network. If you do go to an out-of-network hospital, however, the out-of-network hospital will transfer you to an in-network hospital for ongoing inpatient care once you are well enough.

Questions to ask before you’re admitted to the hospital
It’s important to know that your HMO coverage for your emergency room visit ends if you’re admitted to the hospital. This means that if you are admitted to a hospital that is not in your network of providers, you will be charged the full cost of your treatment and stay. That’s why it is important to contact your PCP if you’re being admitted, so that they can ensure you are referred to a facility that is in your network.

Ask these questions to help you stay informed on cost and HMO coverage:

There’s a lot to consider when deciding where you should go for care. We’re here to help you understand all of your options.

Not all benefits are offered by all health plans. Please refer to your benefit materials or log in or register for your member account, Blue Access for Members to see the limitations and exclusions in your plan. If you want to verify your coverage and identify your medical group and PCP, all you have to do is to visit the My Coverage tab.

Questions? Register for Connect and ask us in the comments!

Disclaimer: The information provided in this document is based on current information, should not be considered comprehensive and should not be relied upon for benefit decisions. It should not be considered legal or tax advice.

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