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Understanding Obamacare: Stronger Out-of-Network Emergency Room Protections

Dec. 2, 2013
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Question: What does “in-network” mean and does health reform change that?

Answer: Before the Affordable Care Act became law, insurance companies often had a network of providers—medical centers they direct you to—in their plans. The two types are broad networks, in which most healthcare providers are included, and narrow networks, in which certain healthcare providers are encouraged. Consumers have the ability to go “out of network” but can expect usually higher deductibles and/or co-pays. Narrow networks are usually cheaper but they somewhat restricts your choice in providers.

Obamacare allows for both narrow and broad networks, and companies must disclose that information clearly on healthcare.gov. But the law does make very important changes to networks and the use of the emergency room.

Prior to Obamacare, insurance companies could require administrative hurdles, “pre-authorizations,” charge higher rates and otherwise limit coverage for those who went to the emergency room out of network. But emergencies happen. Individuals do not often visit the emergency room at the ideal time or location. And if the emergency happened out of your area you could have been left with a much larger bill than normal. Requiring approval before going to an emergency room is a restriction on our freedom of choice at the worst possible time—during an emergency situation.

Now, thanks to Obamacare, insurance companies can no longer require you to have “pre-authorization” for emergency services, nor must you go through an administrative maze to get care. Insurers can no longer charge you higher co-pays or co-insurance than in-network coverage if you are admitted to an emergency room, no matter where you are.

When shopping for health coverage, keep in mind which health systems are in-network for an insurance plan. But rest easy knowing that no matter what happens, if the unthinkable were to occur, you’re protected from excessive costs and gaping holes in your coverage.

—Kevin Kane, lead organizer, Citizen Action of Wisconsin

The Shepherd Express and Citizen Action of Wisconsin will answer questions about the Affordable Care Act during its implementation. Got a question? Email editor@shepex.com.


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