Heath plans must cover emergency care, even if you do not go to a hospital in your plan's network. Any emergency room must treat you until you are well enough to be moved to a hospital in your health plan's network. Your plan must also cover emergency care when you travel outside of your plan's service area.
What Is an Emergency?
The law says that it is an emergency if you reasonably believe that it is an emergency. It is an emergency if waiting to get care could be dangerous to your life or a part of your body. A bad injury or a sudden serious illness can be an emergency. Severe pain and active labor are emergencies. An emergency can also be related to your mental health. Your health plan must cover emergency care no matter where you are and what hospital you go to. Some limitations may apply to emergency services received outside the United States. In addition, you may be moved to a hospital in your health plan's network when you are stable enough to be moved. As a general matter, you may not be balance billed for emergency services, but some limitations may apply to emergency services received outside of California.
What Is Urgent Care?
Urgent care is when your condition, illness or injury is not life-threatening, but you need medical care for which treatment cannot be delayed until you can return to your health plan's service area. Your health plan must cover urgent care when you travel outside your plan's service area. If you are within your health plan's service area, you must use doctors and urgent care facilities in your health plan's network for urgent care.
Be Prepared Ahead of Time
- Ask your primary care doctor what to do if you or your child needs urgent care.
- Ask your primary care doctor or call your health plan to find out where you can go for urgent care or other after-hours care. You can also find out about urgent care in your health plan contract (Evidence of Coverage).
Helpful Hints
- If you can, call your doctor or an advice nurse before you go to the hospital. Ask what you should do.
- Always keep your Membership Card with you.
If your plan will not pay for the emergency or urgent care you received, you can file a complaint with your plan.