If You Need Emergency Care

If you have a medical emergency that's sudden, urgent, and serious or life-threatening, you should go to the nearest physician, hospital emergency room, or other urgent care facility. Your emergency care will be covered at 80% (assuming you have met the in-network annual deductible) under both Option 1 and Option 2 as long as your health care company approves the care as being required for a true emergency.

Care will be approved for local emergency ambulance service or air ambulance to the nearest hospital qualified to treat the condition if medically necessary and confirmed by a licensed provider. It is best for you or your doctor to call your claims administrator to arrange Air Ambulance transport as they can help identify best resources most easily.

If your health care company determines that you did not have a true emergency, the Plan will pay benefits at 50% rather than 80% after meeting the in-network deductible. Non-emergency transportation is covered if it is provided by a licensed professional ambulance (either ground or air ambulance as determined appropriate) when the transport is:

from an out-of-network facility to the nearest in-network facility with capabilities to care for the condition;

to a facility that provides a higher level of care that was not available at the original facility, when medically necessary for the patient's care; or

to a more cost-effective acute care facility (as authorized by the Plan) from an acute facility or to the nearest most appropriate sub-acute facility.

Note: The determination of whether the visit was a true emergency and thus whether coverage is at the 50% or 80% level is determined based on what a prudent layperson would consider an emergency, not on the final diagnosis reached by doctors. True emergency means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part.

Emergency Services from an Out-of-Network Provider

Your coverage for emergency services will continue until your condition is stabilized and:

Your attending physician determines that you are medically able to travel or be transported, by medical or non-emergency medical transportation, to another provider if you need more care;

You are in a condition to be able to receive notice from and consent to the out-of-network provider delivering services for the services to be rendered; and

In the case of a surprise bill from an out-of-network provider where you had no control of their participation in your covered services, you will pay the same cost share you would have if the covered services were received from a network provider. Contact your claims administrator immediately if you receive such a bill.

The out-of-network plan rate does not apply to involuntary services. Involuntary services are services or supplies that are performed at a network facility by certain out-of-network providers, that are not available from a network provider, or which are emergency services. Your cost share for involuntary services will be calculated in the same way as if you received the services from a network provider. If you received a surprise bill, your cost share will be calculated differently. Contact your claims administrator immediately if you receive such a bill.