Patient Protections for Emergency Coverage Under ACA

Under the Affordable Care Act (ACA), health plans must offer regulated coverage for emergency services.

Definition of Emergency Services

“Emergency Services” are defined as acute symptoms that a prudent layperson with average knowledge of health and medicine would expect that in the absence of medical attention would place the individual’s health in serious jeopardy, or seriously impair body functions, organs, or parts. These services would also be performed in the hospital’s emergency department.

Under the ACA, health plans cannot require:

  • Higher copayments or co-insurance for out-of-network emergency room services.
  • Approval before seeking emergency room services from a provider or hospital outside a plan’s network.

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