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Out of Network emergency coverage under ACA... does maximum out of pocket still apply?

Emergency coverage seems to be included under the ACA, although what constitutes an emergency seems to be a very grey area.

If the insurance company agrees that an emergency is covered and maximum out of pocket has been reached will the insurance cover 100% ?

I've asked several representatives at the insurance company and the answers vary, so I thought I'd ask around here.



  • This depends on whether it's considered an emergency or not. If it's not considered an emergency, but the procedures/tests etc are covered under another part of the policy, it will still be covered. HOWEVER, if it IS considered an emergency, most policies cover emergencies at 100%, which means out of pocket will not apply and it will be fully covered by your insurance. If it's considered not emergent, but considered covered under another part of the policy and the maximum out of pocket has been reached, then the insurance will still cover it at 100%.
  • Posts: 58
    I suggest that you ask your insurer for documentation in what is considered an emergency situation; you will be given a listing of these conditions.  Generally considered emergency conditions are non-trivial bleeding,. unconsciousness, difficulty breathing (uncontrollable hiccups would be considered this), dizziness that does not abate, broken bone, burns greater than 1st degree, debilitating pain.  The best thing to do is to go to an actual emergency room, not an urgent care clinic.  If the emergency room, after hearing your description of your condition, does not immediately tell you that you do not have a true emergency condition, then they have de facto determined that you do have such a condition (they can always write up the incident to make it pass the emergency standard,)
  • Posts: 58
    Also, any type of heart irregularity (look up the symptoms of a heart attack).
  • Posts: 70
    Anytime I have heard of an emergency I have heard bad things when it comes to coverage.  That means after the fact the people I have talked to have been through a hassle, to what degree I cannot really say though.  I just think that the information out there is not even enough to know for sure, which is irritating.  Hope I am wrong.
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