The Patient Protection and Affordable Care Act (“ACA”) has a list of ten categories of essential benefits that a health insurance plan must offer. One of these essential benefits is emergency care.
The ACA says that emergency services must be provided without any requirement that services be pre-authorized. This requirement seems to take into account the unplanned nature of most emergency room visits. Plans that comply with the ACA also may not impose any limitation on coverage for services by an out-of-network provider that is more restrictive than the requirements or limitations on emergency department services received in network (see 45 C.F.R. § 156.130 (g)). If emergency services are provided out-of-network, any required copayment amount or coinsurance rate must be the same that would apply if such services were provided in-network.
Non-urgent emergency room usage has been blamed for billions of dollars in “wasteful” spending every year. One of the goals of the ACA is discouraging reliance on emergency departments for routine or primary care.
For many people, the emergency departments of hospitals have become their primary health care providers. According to some studies, close to one-third of the visits to emergency departments were non-urgent (usually defined as visits for conditions that would not have an increased likelihood of an adverse outcome after a wait of several hours).
The choice to go to an emergency room for non-urgent care is often a matter of economics. Since the enactment of the Emergency Medical Treatment & Labor Act (42 U.S.C. § 1395dd) in 1986, public hospitals have been required to provide treatment to uninsured or indigent patients regardless of any inability to pay. One study has also found that using emergency departments for care is also a matter of convenience. Emergency department care, which does not require an appointment and which is available around the clock, is more accessible than ambulatory care. The limitation of business hours is only part of the problem: A significant shortage of primary care physicians is projected to make primary care even more difficult.
While some reports have said that emergency room usage has increased since the enactment of the ACA, there is some doubt as to whether any perceived increase is just a continuation of a pre-existing trend. There is also reason to believe the increase may be temporary, and that emergency department usage will taper off in the future. In any event, whether the trend is for more or less emergency room usage, coverage for that usage will be an important benefit for the insured.
For further information, we invite you to download the following Legal Insights White Paper:
The Affordable Care Act: Mandated Benefits Compliance Standards
Further Reading and References:
New England Healthcare Institute, A Matter of Urgency: Reducing Emergency Department Overuse, March 2010, available at http://www.nehi.net/writable/publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf
U.S. Senate Committee on Health, Education, Labor, and Pensions, Subcommittee on Primary Health and Aging Hearing, Diverting Non-Urgent Emergency Room Use: Can it Provide Better Care and Lower Costs?, May 2011, available at http://www.gpo.gov/fdsys/pkg/CHRG-112shrg81788/pdf/CHRG-112shrg81788.pdf
Lori Uscher-Pines, et al., Deciding to Visit the Emergency Department for Non-Urgent Conditions: A Systematic Review of the Literature, American Journal of Managed Care, January 2013, available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/
Shreya Kangovi, et al., Understanding Why Patients of Low Socioeconomic Status Prefer Hospitals over Ambulatory Care, Health Affairs, July 2013, abstract available at http://content.healthaffairs.org/content/32/7/1196.abstract
American Academy of Family Physicians, Significant Primary Care, Overall Physician Shortage Predicted by 2025, March 2015, available at http://www.aafp.org/news/practice-professional-issues/20150303aamcwkforce.html
Brian Wu, ER Visits Rise Despite Obamacare Goals, The Science Times, May 2015, available at http://www.sciencetimes.com/articles/6241/20150511/er-visits-rise-despite-obamacare-goals.htm
Katie Bo Williams and Julie Henry, What that ED Visit Study Got Wrong and What it Got Right, Healthcare Dive, May 2015, available at http://www.healthcaredive.com/news/what-that-ed-visit-study-got-wrong-and-what-it-got-right/395299/