When An Out-Of-Network Emergency Room Must Be Paid For By Insurance?

The Affordable Care Act (ACA) mandates that health insurance plans cover out-of-network emergency care as if it were in-network care. This means that patients cannot be charged more in copayments or coinsurance if they receive emergency care from an out-of-network hospital. The No Surprises Act, which came into effect on Jan. 1, 2022, requires health insurance plans to cover such services at in-network rates.

Out-of-network health care charges can be significant, and many states have laws requiring plans to cover such services at in-network rates. Health insurance covers emergency room visits, but there are usually copays or coinsurance amounts, and you may have to pay your deductible. In most cases, plans are not required to cover care received from a non-network provider, though there are important exceptions.

In emergency situations, health insurance companies can’t require prior approval from patients. However, if the treatment was truly an emergency and the patient went to the nearest emergency room capable of treating their condition, the insurance will likely cover the treatment as if it was an emergency. If the treatment was truly an emergency, the deductible or some copay or coinsurance should not be paid as OON.

When emergency care is received by out-of-network providers, the cost-sharing requirement must match in-network rates. With prior approval from your insurer, you may be able to receive the care you need out-of-network and still pay only the lower, in-network rate. Sometimes, your insurance will pay a reduced rate or nothing. Your coverage specifies what it pays for out-of-network care.