Let's say I have a HMO policy I bought on the marketplace from South Carolina and I'm on a road trip across the country. While I'm in New Mexico, I go to the ER for an emergency (not in network) and I am admitted or even have surgery during the admission.
EDIT:
I believe I found the answer to all questions. Leaving this up if it helps anyone else. Questions 1 and 3 in this document and question 2 is addressed here.
Would the hospital admission or surgery be covered under the no surprises act? If they are covered, I'm assuming the no surprises act stops as soon as the patient is safe to be discharged- is that a correct assumption?
Would my copayment/coinsurance for my ER visit/admission count against my out-of-pocket max? My insurance has no out of pocket max for out of network coverage, but does the no surprises act supersede this in the case of an emergency?
What determines the definition of emergency care? Is it based on certain billing codes or other parameters?
@silverback Unfortunately, that document was not very useful in answering any of the questions, but I was able to answer all my questions with a document I was sent.
@principiatheologica The first question is kind of a gray area that's dependent on the scenario and open to interpretation and is one of the issues that periodically comes up here. It's one thing to fall and break your leg skateboarding and need immediate surgery as a compound fracture is causing bleeding and the nearest in-network hospital is three states away. It's another thing to break your leg skateboarding and be stabilized in an air cast and then scheduled for orthopedic surgery next week and the nearest in-network hospital is down the street.
The previous standard as to when "Emergency" care becomes "Non-emergency" was when you were stable enough to be transferred via a standard ambulance to an in-network facility, the No Surprises Act revised that to be "non-medical or non-emergency medical" transportation. In any scenario it's required that you or someone on your behalf (and an out-of-network hospital is not required to do this) notify the insurance company that you've been admitted to an out-of-network facility.
@mountaintrip98 Yes, after reading some of that document the OP posted in regard to question no. 1, it's an extremely gray area and can only be determined on a case by case basis.
