Covering Medical Care While Out of the State or Country
Being injured or finding yourself sick while you are out of the state or country – perhaps on vacation – can be a frightening experience. When you are home, you have your own doctors, you know where the hospital is, and a relatively minor injury or illness is no big deal. You hand over your insurance card, confident that your insurer will pay as it has promised. But what happens if you are out of the state or out of the country? Will your insurer pay for an ambulance, an ER trip, an urgent care visit, or an all-out major injury or illness? What about if you need to be flown home? The answer to these questions is, “maybe.”
The type of insurance you have will have a direct bearing on whether you will be stuck paying for medical care you received while out of your home state. If you have had a medical emergency while you were away from home and your insurance company is balking at paying for your care, it can be beneficial to speak to an experienced insurance denial attorney from the Law Offices of Scott Glovsky. If your insurer has denied a medical claim because you were not in your home area, attorney Scott Glovsky can help you determine whether it is within its rights to do so. If not, Scott will fight for your rights and for justice.
Does Health Insurance Cover You When You Are Out-of-State?
While keeping in mind that every insurance company is different and has its own rules regarding out-of-state medical coverage, generally speaking, if you have a PPO (Preferred Provider Organization) or an OAP (Open Access Plus) medical insurance plan, you are usually entitled to full access to all participating providers in the carrier’s network – regardless of what state you live in or what state you happen to be in. PPO and OAP plans are often offered through your employer.
With a PPO, you are not required to select a primary care physician and can see any provider, in or out-of-network, without a referral. You can fill your prescriptions anywhere you choose, and even for out-of-network providers, you will usually get by with paying about 40 percent of what the plan considers “reasonable and customary” charges once you pay your out-of-network deductible. So, while you should check your plan or call your provider to be sure, out-of-state medical care is likely to be covered if you have a PPO plan.
An OAP plan also allows full access to any participating provider in the carrier’s network, regardless of your state. Those with an OAP plan usually have three tiers of providers from which to choose, and the benefit level is determined by the tier in which the healthcare provider is contracted. Members enrolled in an OAP can mix and match tiers and providers. If there are participating providers in the insurer’s national network, your plan will pay for out-of-state care at an in-network level, even if your medical needs are not considered an emergency.
If you have HMO (Health Managed Organization), EPO (Exclusive Provider Organization), or POS (Point of Service) health insurance, you are less likely to be covered when you are out of state – unless it is an emergency. If you get your insurance through the Affordable Care Act (AKA Covered California in California(, you are more likely to have HMO coverage but could possibly have PPO coverage.
Most people who get their insurance through the Affordable Care Act are likely to be eligible for out-of-state services but not out-of-country services. POS health insurance provides access to healthcare services with fewer choices but at a lower cost and is usually considered a hybrid of an HMO and a PPO plan. EPO insurance only covers in-network services unless it is an emergency.
With HMO and POS plans, most out-of-state care is seen as out-of-network care, so it is not typically covered. If, however, you are traveling to or through another state and you are involved in a serious car accident, you will be taken to the nearest hospital, which would normally not accept your insurance. This is true except in emergency situations. Emergency care is almost always billed as “in-network” by HMO and POS insurance.
Unfortunately, insurance companies often have different ideas of exactly what constitutes an emergency. An insurer may deny a claim because it does not consider it true emergency treatment. Perhaps you sprained your ankle skiing out of stateand expect your HMO insurer to consider that an emergency and pay the hospital bill.
You might be surprised when your insurer deems a sprained ankle not an emergency and refuses to pay. If this occurs, you do have some recourse. You can appeal the denial through an internal appeal and then an external appeal if the internal appeal is unsuccessful.
Does Medicare Cover Out-of-State Injuries and Illnesses?
Original Medicare (AKA Traditional Medicare) benefits are considered “portable,” in that you can travel to all 50 states as well as Washington, D.C., Puerto Rico, The U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands, and Medicare will pay for your medical treatment – even if it is not an emergency. There are no restrictions, and you can see any provider that accepts Medicare.
The coverage is not as simple if you have a Medicare Advantage plan. Some Medicare Advantage plans provide state-to-state coverage, while others will not cover anything outside its defined service area. The exception is emergency or urgent care medical needs, which Medicare Advantage plans are required to cover anywhere in the United States with no out-of-pocket costs and no additional restrictions.
Some Medicare Advantage plans that do pay for out-of-state, non-emergency care may limit the amount of time you can spend outside your “service area” and still be covered. The amount of time is usually six months; if you stay longer than that, you may be disenrolled from your Medicare Advantage Plan and enrolled in original Medicare.
If your Medicare Advantage plan requires that you have a referral from your primary care provider (PCP) for a specialist visit, you will need to select a new PCP near your temporary residence if you spend half the year in one state and the other half in another state.
Check Your Policy Carefully Before Traveling Out of State
Whether you have an HMO, PPO, POS, EOS, or OAP plan, checking your health insurance coverage before leaving your home state is always a good idea. There can be a significant difference in how out-of-state injuries and illnesses are covered from one insurer to another. You can call your provider and ask about its policy for out-of-state injuries and illnesses, or you can read through your plan documents to determine whether you will be covered if you need medical care while you are away from home.
Are International Medical Needs Covered by Insurance?
If you have original Medicare or Medicaid (AKA Medi-Cal in California), no medical costs – even for an emergency – will be paid by your insurer. If you get your insurance through your employer, some of your medical expenses might be covered, but this is not typical. Some Medicare Advantage plans do offer out-of-country medical services, but most do not. Even if your plan does cover out-of-country medical needs, it will most likely be restricted to only emergency services. As mentioned above, your plan may have a different idea of what an emergency medical service consists of.
What is Travel Medical Insurance?
If you are planning to travel out of the country and hope you will remain healthy during your trip, consider what would happen if you were injured or became seriously ill while in a foreign country. Travel medical insurance can help cover the cost of many emergency treatments (not routine healthcare) when you are out of the country.
Knowing that your vacation budget will not be completely destroyed by an unexpected medical emergency when you have travel medical insurance can give you peace of mind. Travel medical insurance can also help with communication when you do not speak the language of the country you are planning to visit.
Consider travel medical insurance a supplemental healthcare policy that is only valid for the length of your trip and supplements your own health insurance when you are not in the United States. Remember – travel medical insurance is not meant to be used for regular medical care or preventative treatments, only for emergencies, including:
- Stroke
- Heart attack
- Emergency dental procedures
- Broken bones
- Medical evacuations
- Emergency medical transport
- Emergency repatriation
Some countries, including the United Arab Emirates, Turks and Caicos, St. Maarten, French Polynesia, Costa Rica, and Aruba, may require proof of travel medical insurance prior to entering their country.
Where Do I Get Travel Medical Insurance and How Much Does It Cost?
You can purchase standalone medical travel insurance or a comprehensive travel insurance policy that covers emergency medical and dental expenses, medical evacuation, and repatriation. A standalone plan may be referred to as an emergency medical plan. Comprehensive travel insurance usually bundles medical coverage with additional benefits like trip cancellation refunds, baggage loss, and trip delays.
If you are booking your trip through a travel agency, ask about medical travel insurance. If you are booking a flight online, there is usually an option to purchase comprehensive travel insurance – but not always. There are websites that can help you compare different travel medical insurance plans to determine which one is best for you.
Some of the companies that provide this insurance include AIG, Allianz Global Assistance, Travelex Insurance, IMG, Travel Insured International, John Hancock, Global Trip Protection, and Seven Corners. You may also have the option to purchase only medical evacuation insurance, which covers the cost of transporting you to a medical facility when you are outside the U.S.
Travel medical insurance usually costs from $40 to $125, but depends on many factors including your age, the length of your trip, your specific state of health, the type of coverage you want, and so on. That said, the cost is typically a relatively small price to pay so you will not have to worry about paying for a medical emergency. You can also get very specialized forms of travel medical insurance that are dependent on the activity you will be doing while on vacation. For example, you can get travel medical insurance for a scuba diving trip.
If you plan on paying for your international trip with a credit card, check with your credit card company to see whether it comes with certain types of insurance, including car rental insurance, trip cancellation insurance, purchase warranty insurance, and travel medical insurance.
Will the No Surprises Act Help Cover Some of My Medical Costs?
Effective on January 1, 2022, the No Surprises Act helps protect people from surprise medical bills. This law applies when your both your health insurance plan and the provider are in the United States. As such, the NSA could help you if you receive medical care outside of your home state, but likely not if you receive care outside of the country.
How the Law Offices of Scott Glovsky Can Help
Thanks to the high costs of medical care, health insurance is a huge issue in our lives. Getting injured or learning of an illness when you are out of the state or out of the country could potentially devastate your finances. Regardless of what your insurance issue is, attorney Scott Glovsky and his legal team are ready to help you get through a difficult time in the best way possible and with the best outcome possible.
Attorney Scott Glovsky founded his firm in 1999 with the goal of holding major corporations accountable for putting their profits over people’s lives. Scott is a skilled trial lawyer who is determined to make a real difference in his clients’ lives while changing the system so others are not forced to suffer needlessly. If your insurance company is refusing to pay a claim it should rightfully pay, contact the Law Offices of Scott Glovsky.