Evaluating Access To Emergency Care Through Your Health Plan

A Checklist For Consumers

Many individuals learn about the emergency medical benefits of their health plan when they are in the midst of a medical crisis.  The American College of Emergency Physicians (ACEP) has developed this checklist to assist you in evaluating your health plan's emergency medical benefits in advance.

1. The insurance/health plan has given me written materials that clearly explain what to do if I need emergency care, including:

   1. when to call for an ambulance or 9-1-1,
      Yes _________ No _________ Don't Know _________
      
      
   2. how to call for an ambulance,
      Yes _________ No _________ Don't Know _________
      
      
   3. when to seek emergency care,
      Yes _________ No _________ Don't Know _________
      
      
   4. and where to go for emergency care.
      Yes _________ No _________ Don't Know _________
      
      
      
2. The insurance/health plan encourages me to call an ambulance or go directly to the emergency department if I think I have an emergency medical condition.
   
   Yes _________ No _________ Don't Know _________
   
   
   
3. The insurance/health plan has given me written material that clearly explains that they will pay for a visit to an emergency department if I have symptoms that most people would consider an emergency (the "prudent layperson" standard) even if it later turns out that my condition was not a true emergency.  For example, I have chest pain that I think is a heart attack, but it turns out to be indigestion.
   
   Yes _________ No _________ Don't Know _________
   
   
   
4. The insurance/health plan has given me a telephone number that I can call when my doctor's office is closed.
   
   Yes _________ No _________ Don't Know _________
   
   
   
5. When I call this number I am able to speak with a qualified nurse or doctor who can give me advice about my problem and help me decide if I need to go to an emergency department or other health care site for treatment of my problem.
   
   Yes _________ No _________ Don't Know _________
   
   
   
6. The insurance/health plan does not require that I call them before I go to an emergency department as a condition for paying for the emergency services (i.e., there is no "preauthorization requirement").
   
   Yes _________ No _________ Don't Know _________
   
   
   
7. The insurance/health plan does not require the emergency department staff to call them before an emergency physician or nurse has examined me to determine if I have a medical emergency.  (Federal law requires that a medical screening examination must be performed on every emergency department patient regardless of ability to pay.)
   
   Yes _________ No _________ Don't Know _________
   
   
   
8. After the emergency physician has evaluated me, the health plan has qualified medical professionals readily available to discuss my condition and make arrangements for any further treatment.
   
   Yes _________ No _________ Don't Know _________
   
   
   
9. The extra payment (co-payment or deposit) I have to pay out of my own pocket is not so high that it would discourage me from going to an emergency department when I believe I need emergency medical care.
   
   Yes _________ No _________ Don't Know _________
   
   
   
10. Hospitals approved by the plan are located conveniently to me.
    
    Yes _________ No _________ Don't Know _________
    
    
    
11. I am able to see my regular doctor, as well as any specialists I might need, in a timely manner for urgent and routine medical conditions.
    
    Yes _________ No _________ Don't Know _________
    
    

Rating Your Insurance Plan and Services

YES responses to the above questions tend to indicate that your health plan supports appropriate emergency care access.  NO responses indicate that there may be a problem.  DON'T KNOW responses may indicate that you need to ask additional questions of your insurance plan in order to fully understand your coverage.

To obtain more information, check with the plan's customer service representative or the agency responsible for regulating health care plans in your state (in most cases this is the Department of Insurance or Department of Corporations).

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Material taken from the American College of Emergency Physicians.