Emergency Room Services
Explanation
Plans that cover emergency services are required to provide such coverage without the need for prior authorization, regardless of the participating status of the provider, and at the in-network cost-sharing level. The regulations require that plans or issuers not seek pre-authorization or pre-certification for emergency services. Notification requirements are permitted. There is also a new payment methodology for emergency services performed out of network; however, this is not applicable if the plan/issuer is contractually responsible for balanced billed amounts or where a state law prohibits balance billing so long as clear notice is provided to members regarding lack of financial responsibility.[Section 2719A of H.R. 3590]
Aetna’s take and action
- Aetna already applies an in-network cost share to emergency services provided by non-participating providers and does not require pre-authorization for such services.
- We are expanding our “hold the member harmless” approach to our Traditional Choice and Open Choice plans, the only plans for which it was not previously in effect. We are making this change regardless of grandfathered plan status. This means that if members receive balance bills, for cost share amounts from non-participating providers for emergency services, we will review, and members will not be held responsible for the difference.
- To facilitate this approach, we are making our EOB messaging clearer, and we are developing appropriate language for plan documents.
Questions and answers
- May a plan require prior authorization for emergency services?
- How are emergency services defined?
- May out-of-network providers balance bill?
View all Emergency Room Services Q&As
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