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Emergency Services Insurance Coverage

What is an Emergency?

"In general, the law says it's an emergency if a reasonable person who does not have medical training would think it's an emergency."

Where to Find Help

Hospital Emergency Departments are required by both federal and state law to screen and stabilize, within the capability of the hospital, any patient who presents to the Emergency Department with an emergency medical condition without regard to insurance coverage.

However, If you do have insurance that covers emergency care, California law requires your insurer to pay the same benefit at any hospital providing your emergency care, even if that hospital is not in your insurer's hospital network. Two agencies govern California Health Plans and Health insurance companies, The California Department of Managed Health Care and The California Department of Insurance. If your company is listed with either of these sites they are obligated to follow these guidelines. To check the California Department of Managed Health Care, click here to see a list of companies regulated by the Department of Managed Care.

If your insurance company is not listed under the site above click here. This page will enable you to complete a search for your insurer's name.

Emergencies and Urgent Care

In an emergency, you should call 911 or go to the nearest emergency room. Your HMO must cover emergency care. If you can, try to go to a hospital in your HMO network. However, any emergency room must treat you until you are well enough to be moved to your own hospital. Your HMO must pay for this treatment. In general, the law says it's an emergency if a reasonable person who does not have medical training would think it's an emergency.

FAQ's

Q: What if it's an emergency and the nearest hospital is not in my HMO's network?
A: Your HMO will cover emergency care at any hospital. But you should call your HMO as soon as
     possible. Your HMO may move you to a hospital in your plan when your condition is stable.

Q: What about ambulance service?
A: Your HMO must cover ambulance services in an emergency.

Q: What if my HMO refuses to pay for my emergency care?
A: You and your HMO may not agree on what problems require emergency care. If this happens,
     you can file a complaint.

How to File a Complaint with Your HMO

1. Ask your HMO Member Services to send you a complaint form.
2. Your HMO must take action within 30 days after it receives your complaint.
3. If your problem is urgent, ask for an Expedited Review. Your HMO must take action within 3 days.
4. If your HMO still won't help or doesn't reply within the time limit, call the HMO Help Center at
    1-888-HMO-2219.

How to File a Complaint with the HMO Help Center

1. Unless your problem is urgent, you usually need to file a complaint with your HMO first.
2. If your HMO doesn't take action within 30 days or you still need help, you can file a complaint with
    the HMO Help Center

To file a complaint, call HMO Help Center (1-888-HMO-2219).
To see a complaint form visit: www.hmohelp.ca.gov

Request an Independent Review

You and your HMO may disagree about the care you need. Your HMO may say that the treatment you've asked for is not necessary for you health or is experimental. Or you may have gotten emergency care that your HMO won't pay for.

If these things happen, you can ask for an Independent Medical Review, or IMR. The State of California hires an independent organization to conduct these reviews. This organization has doctors who review the cases. The doctors are experts on your condition, but they are not part of your HMO. And they do not get any money from your HMO. To request an Independent Medical Review (IMR), call the HMO Help Center.

Where to Find Help

Office of the Patient Advocate (OPA)
Information on California's HMOs
1-866-HMO-8900
http://www.opa.ca.gov/

HICAP
(Health Insurance Counseling & Advocacy Program)
Information, counseling and advocacy for Medicare Members
1-800-434-0222

HMO Help Center
Information and assistance for California HMO members
1-888-HMO-2219
http://www.hmohelp.ca.gov/

*Information provided by the California HMO Guide.