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Beware: Your Insurer May Define A Health Emergency Differently Than You Do

On a frosty late February morning, Dennis Doman awoke with the metallic taste of blood in his mouth.

Throwing off the blankets, he padded the few steps to the bathroom sink. He coughed and then coughed again.

The third time, he spewed blood. He bled so profusely, “I turned my bathroom into a crime scene,” he says.

Doman called 911 and was rushed to a hospital. The initial diagnosis was a gastrointestinal problem.

“I told them no because I can taste blood,” remembers Doman, 64.

Further tests revealed Doman was right – it wasn’t his stomach. The next day, he was sent to Thomas Jefferson University Hospital, where doctors discovered he had a cancerous mass in his neck.

The mass was successfully removed, but over the next six weeks, Doman endured a series of emergency-room and operating-room visits. Throughout his experience, the former warehouse manager’s biggest worry was whether his UnitedHealthcare Silver Compass 100 plan would cover the cost of his care.

“The doctors assured me that I was covered,” he says.

The bills he has received since, he says, and those mounting on his UnitedHealthcare account, say otherwise.

All he knows for sure is that at a time when he felt in no shape to figure out the intricacies of health coverage, that’s exactly what he needed to be doing.

In an emergency, whether a doctor or hospital is in a plan’s network doesn’t matter. Every health insurance plan – whether purchased on the Affordable Care Act marketplace, employer-based, or privately purchased – allows you to go to the nearest hospital.

But what people might not realize is that once you are stabilized, you must transfer to an in-network doctor or hospital. If you don’t, you are responsible for the cost of your care. And you won’t be saved by the ACA’s yearly maximum out-of-pocket costs of $6,600 for an individual and $13,200 for a family.

“The out-of-pocket maximum only applies to in-network services,” says Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. “So they would lose that protection once the emergency is over if they’re still getting services out of network.”

Doman’s experience is in part a cautionary tale about choosing a health plan wisely. Don’t look at just the monthly premium amount. Dig into every aspect, from deductible to co-pays to coinsurance. Make sure that the pharmacy formulary covers your prescriptions and that the network includes your doctor and preferred hospital.

Some plans do allow customers to use out-of-network providers, but they still must pay extra.

“It is part of the plan design,” says Mary McElrath-Jones, director of public relations for UnitedHealthcare. “The plan will tell you this is what we pay if you are in network and this is what we pay if you are out of network. So you will know up front whether you have an out-of-network benefit.”

Doman’s Silver Compass 100 does not include an out-of-network benefit. He sees the result every time he examines his bills, which he says are near $200,000 – though that might be hospital charges, not the amounts he would really be expected to pay.

McElrath-Jones says Doman does have “some out-of-network bills associated with Jefferson,” because of follow-up visits with an out-of-network doctor. “We have taken steps to double-check and fully review each of Mr. Doman’s charges to ensure they are absolutely correct. We will continue to scrutinize the medical bills for him.”

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