Emergency and Urgent Care
Emergency Care
Emergency care received from an out-of-network provider will be paid at the network benefit level. This means the deductibles and coinsurance will be the same, whether the hospital is a network facility or not. However, you are responsible for any charges by the out-of-network provider that exceed the allowable charge.
Emergency Room Services
Benefits are provided for treatment in a hospital emergency room. A $50 emergency room copayment will apply to your first visit in a calendar year. For any additional emergency room visits during the year, a $200 copayment will be applied. The emergency room copayment is separate from your deductible and coinsurance amount. If you are admitted to the hospital, the copayment is waived. Emergency room services should only be used in emergency situations.
Ambulance Services
Benefits are available for covered ambulance services when they are medically necessary as determined by the medical claims administrator. Ambulance services include transportation by a specially equipped vehicle for the sick and injured under these circumstances:
From the place of injury or illness to the nearest appropriate facility for treatment.
From a hospital to another hospital or freestanding facility for specialized services not available at the initial hospital, and back.
From one hospital to another when the initial hospital lacks adequate treatment facilities, and the receiving hospital has the needed facilities.
Air ambulance services are covered when the participant's condition or the urgency of the needed medical care makes surface transportation impractical. This includes helicopter transportation to the nearest facility equipped to treat the participant’s condition. Fixed-wing air transportation is for long-distance travel only and is not usually considered an air ambulance service.
Ambulance service benefits will not be provided solely for a participant's comfort or convenience.