You will not be responsible for the costs of “emergency services” you receive in a hospital, other than any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies to such services under your plan. This is true even if:
- You receive the emergency services at an out-of-network hospital, or
- An out-of-network provider provides you services during an emergency hospital visit.
What are emergency services?
Emergency services generally refer to the following hospital services to treat an emergency condition:
- Medical screening exams that a hospital’s emergency department can perform, including ancillary services routinely used to assess emergency medical conditions, and
- Examens médicaux et traitements supplémentaires nécessaires pour stabiliser un patient.
Une condition d'urgence signifie une condition médicale ou comportementale qui produit des symptômes suffisamment graves pour la qualifier de condition d'urgence. Par exemple, si vous ressentez une douleur intense qui, selon vous, pourrait entraîner une ou plusieurs des situations suivantes sans obtenir de soins médicaux immédiats:
- Danger extrême pour la santé de la personne confrontée à la situation d'urgence ou à un problème de comportement
- Atteinte grave aux fonctions corporelles de la personne affectée
- Dysfonctionnement grave d'un organe corporel ou d'une partie de la personne affectée
- Défiguration grave de la personne affectée
What are some examples?
Here are examples of times you would be responsible only for the in-network cost-sharing for out-of-network emergency services:
- You go to an in-network hospital emergency department and an out-of-network physician is brought in to perform services to treat the emergency condition
- An ambulance takes you to an out-of-network hospital and you receive emergency services at that out-of-network hospital
Here are examples of times these protections would not apply:*
- You receive services from a provider at an out-of-network urgent care center, rather than in a hospital
- You receive services in a hospital that do not qualify as emergency services, according to the above definition of emergency services
How does Beacon Health Options process claims for out-of-network emergency services?
If Beacon Health Options receives a claim for emergency services from an out-of-network provider, we’ll pay the claim at the amount we determine to be reasonable for the emergency services — except for any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan.
If we pay an amount less than what the out-of-network provider charges, Beacon Health Options will send you a notice — either within, or together with, your Explanation of Benefits — explaining that:
- Your out-of-pocket costs for the emergency services won’t be any higher than if you’d received them from an in-network provider,
- Your cost-sharing for the emergency services may increase if an IDRE (independent dispute resolution entity) decides Beacon Health Options must pay an additional amount(s) for physician services, and
- You should contact Beacon Health Options if the out-of-network provider bills you for the out-of-network emergency services for amounts greater than your in-network cost-sharing for the services. For instructions, scroll down to “What to Do If You Get a Bill for Out-of-Network Emergency Services or Surprise Bills.”