- If you think you are having a medical emergency, call 911 or go to the nearest emergency room. Most health plans must cover emergency care anywhere in the United States at in-network cost sharing, without prior approval.
- Non-emergency care away from home depends on the plan type. HMO and EPO plans often pay nothing outside their service area. PPO plans usually pay less.
- Outside the United States, many plans, including Original Medicare, provide little or no coverage.
The Okafor family drove nine hours to spend Thanksgiving week with grandparents. On the second day, their eight-year-old developed an earache and a fever of 102. It was a Wednesday evening. The nearest clinic with open hours was an urgent care center a mile away.
The visit took forty minutes. The bill, which arrived in January, was $310. Their plan was an HMO whose network covered one metropolitan area, three states away. The claim was denied as out of network and not an emergency.
A phone call before the visit would have shown them two covered options. This article lays out how plans treat care away from home, so the call is made before the trip instead of after the bill.
Three kinds of care, three sets of rules
Health plans sort care on the road into three groups. Nearly all the confusion comes from not knowing which group a visit falls into.
Emergency care
Federal law requires most health plans to cover emergency services without prior authorization, whether or not the hospital is in the network, and to apply the same copay, coinsurance and deductible that an in-network emergency room would carry. The No Surprises Act adds that an out-of-network emergency facility and its clinicians generally cannot bill you for the difference between their charge and what the plan pays.
Plans must judge an emergency by the “prudent layperson” standard. The question is whether a person with average knowledge of health would reasonably believe the symptoms needed immediate attention. It is based on the symptoms you arrived with, not on the final diagnosis. Chest pain that turns out to be indigestion is still an emergency visit.
One gap to know about: the federal protection covers air ambulances but not ground ambulances. An out-of-network ambulance ride can still produce a separate bill. We explain why in Your ER Visit Was Covered. So Why Did the Ambulance Send Its Own Bill?
Urgent care
Urgent care is for problems that need attention within a day or so but are not emergencies: ear infections, minor cuts, sprains, a urinary tract infection. This is the gray zone. Some plans cover out-of-area urgent care as if it were in network. Some cover it only at centers that belong to a partner network. Some do not cover it at all. The Okafors’ plan would have paid for a visit to a contracted urgent care chain twelve minutes further away, or for a video visit through the plan’s telehealth service.
Routine and follow-up care
Checkups, physical therapy, lab monitoring, specialist appointments and prescription renewals are almost always tied to the home network. That includes follow-up care after an emergency. Once you are stable and able to travel, the plan expects you to return to in-network providers.
What your plan type means on the road
| Plan type | Emergency care in the U.S. | Non-emergency care away from home |
|---|---|---|
| HMO or EPO | Covered at in-network cost sharing. | Usually not covered outside the network. Many Marketplace plans are this type, with regional networks. |
| PPO or POS | Covered at in-network cost sharing. | Covered at a lower rate, often with a separate, higher deductible. The provider may bill you for the balance. |
| Plans with a national or partner network | Covered at in-network cost sharing. | In-network rates may apply at participating providers in other states. Use the plan’s own directory to confirm. |
| Original Medicare | Covered. | Covered nationwide with any provider that accepts Medicare. |
| Medicare Advantage | Emergency and urgently needed care covered anywhere in the U.S. | Routine care generally limited to the plan’s network and service area. Some plans offer a travel or visitor benefit. |
| Medicaid | Emergencies are generally covered out of state. | Usually limited to the home state. Rules vary. |
If you are not sure which type you have, the letters are often printed on the front of the insurance card. Our guide You Look at Your Insurance Card. But Are You Missing This? shows where to look.
The ten-minute call before you leave
1. “I will be in [city, state] from [date] to [date]. Do I have in-network providers there?”
2. “If I need urgent care that is not an emergency, where can I go and what will I pay?”
3. “Does my plan include telehealth visits, and can I use them from another state?”
4. “Can I get an early refill of my prescriptions before I travel?”
Write down the answers, the date and the name of the person you spoke with. Then save two things on your phone: a photo of both sides of the insurance card, and the plan’s app or mobile website with its provider search. Searching the plan’s own directory by your travel ZIP code is more reliable than calling a clinic and asking, “Do you take my insurance?” Front desk staff often answer for the insurance company’s name and not for your specific network.
Telehealth, the option people forget
Most plans now include video or phone visits, either with the plan’s contracted service or with your own doctor’s office. For common problems on the road, such as a rash, a sinus infection, pink eye or a prescription that ran out, a telehealth visit can be covered at a low copay no matter which state you are in.
There are two limits. Clinicians are licensed state by state, so your regular doctor may not be allowed to treat you while you are physically in another state. The plan’s national telehealth service usually solves this by connecting you with a clinician licensed where you are. And telehealth cannot handle everything. A possible fracture, a deep cut or trouble breathing needs in-person care.
Prescriptions on the road
Ask for a vacation override
Plans normally refuse a refill until most of the previous supply should be used up. Many will approve an early refill for travel if you or the pharmacy call ahead.
Use a national chain
If your prescriptions are at a chain pharmacy, another location can usually access the record and fill what is due. Confirm that the chain is in your plan’s pharmacy network.
Carry a list
Keep the name, dose and prescriber of each medication on your phone. An emergency room or urgent care clinician can work much faster with it.
Pack it in carry-on
Keep medication in original labeled containers and in the bag that stays with you. Controlled substances are harder to replace away from home.
If something happens during the trip
- Emergency symptoms: call 911 or go to the nearest emergency room. Do not stop to check networks.
- Not an emergency: call the number on your card, or the plan’s nurse line if it has one, and ask where to go. Consider telehealth first.
- At the facility: show your insurance card and ask them to bill your plan. Decline to sign any form waiving your surprise billing protections for emergency care.
- If you are admitted: have a family member notify the plan as soon as reasonably possible. Some plans ask for notice within a day or two of an emergency admission.
- Before you go home: get copies of the discharge summary, test results and any prescriptions, so your own doctor can continue care in network.
Keep every receipt. If you had to pay at the time of service, you can submit a claim to the plan yourself. The plan’s website has the member claim form, and there is usually a filing deadline.
When the bills arrive
Bills from an out-of-state emergency can come from several sources: the hospital, the emergency physician group, a radiologist, a laboratory, the ambulance. Wait for the Explanation of Benefits for each one before paying. For emergency care, the EOB should show in-network cost sharing even though the providers were out of network.
If a provider bills you more than the amount the EOB lists as your responsibility for emergency care, that may be a balance bill the No Surprises Act prohibits. Call the plan first. If that does not resolve it, the federal No Surprises Help Desk at 1-800-985-3059 takes complaints.
If the plan denies an emergency claim because the final diagnosis was minor, appeal. The prudent layperson standard looks at the symptoms, and a short letter describing what you experienced and why you believed it was serious is often enough to reverse the decision. See ER, Urgent Care or a Video Visit? The Choice That Can Change Your Bill for how plans separate these settings.
Leaving the country
Coverage rules change sharply at the border. Many U.S. health plans cover only emergencies abroad, some cover nothing, and foreign hospitals frequently require payment up front and leave you to file for reimbursement. Original Medicare generally does not pay for care outside the United States except in a few narrow situations. Some Medicare Supplement policies include a foreign travel emergency benefit that pays 80 percent of covered costs after a $250 deductible, during the first 60 days of a trip, up to a $50,000 lifetime limit. Some Medicare Advantage plans add emergency coverage abroad as an extra.
Medical care on a cruise ship is typically billed to you directly by the ship. A medical evacuation flight home can cost tens of thousands of dollars and is rarely covered by ordinary health insurance. For international trips and cruises, a travel medical policy with evacuation coverage is worth pricing. Read what it excludes, especially for pre-existing conditions.
Longer stays: students and seasonal residents
A college student four states from home, or a retiree who spends the winter in a warmer state, is not really traveling. For months at a time, routine care happens far from the plan’s network. If that describes someone in your household, check during open enrollment whether the plan has in-network providers in both places. Students can compare the school’s health plan. People on Medicare who live in two states often find Original Medicare with a supplement more flexible than a regional Medicare Advantage plan, though it can cost more each month.
Nobody should hesitate over network rules in a real emergency, and the law is written so they do not have to. For the smaller problems that make up most holiday mishaps, one call to the number on the card, made before the trip or before the visit, is usually what separates a copay from a bill for the full charge.
Sources: HealthCare.gov, getting emergency care; Centers for Medicare & Medicaid Services, No Surprises Act consumer protections; Medicare.gov, travel coverage and Medigap foreign travel emergency benefits; U.S. Department of State, guidance on insurance coverage overseas. This article is general information and is not medical advice. Coverage depends on your specific plan.