HMO insurance.....what happens if you go to a hospital that's not your site number?

Question

I have HMO, and I have to go the the doctor and hospital that they have on record for my site number, etc.....even if a place takes HMO, i can't go there if it isn't my site number. But if I had an emergency and called 911, the ambulance takes people to a hospital that doesn't even accept HMOs.....if i have a real emergency, I'm gonna call 911, not find a way to get to the other hospital....how does this work - does that mean I HAVE to pay everything out of pocket - is there no way around this??? I am pregnant and labor very fast, if i don't make it to my hospital, 911 would take me there and I can NOT afford birth....god forbid if i needed a c-section.....out of pocket - but i HAVE insurance - they should pay something, right?

Answer 1

Hi Abby,

Congratulations on having your baby!

Most states do in fact have laws that state in the event of a true emergency, an ambulance will take you to the nearest facility from where you're at.  NO QUESTIONS ASKED.

You would not have to pay everything out of pocket.  The insurance would cover it.

Good luck and happy delivery!

Kathy K

www.premiumwatchdog.com

Answer 2

A true medical emergency should be covered at any hospital.  In a medical emergency, they'd likely stabilize you at the out of network hospital, then transfer you to the appropriate hospital.

If you're talking about a normal labor and delivery, that would never be considered a medical emergency.  (Unless there was a complication, of course...but I assume you're talking about just going into labor in general.)  Labor and delivery is a natural process...not an immediate trauma.  You'd have a very hard time convincing your HMO to cover a delivery at a non-HMO hospital without there being some sort of extenuating circumstance.

"Medical emergency" is determined by the admitting diagnosis that is billed on the medical claim.  There are industry standard definitions as far as what diagnosis codes are considered "emergency" and what ones are "non-emergency."  Its not something your insurance company arbitrarily decides.

Additionally - you may want to rethink your plan to use 911 to take you to the hospital to deliver your baby.  Or, at least check with your insurance company first to find out whether they would cover that ambulance ride.  (Most insurance companies specifically cover "emergency ambulance transportation".  This is done to prevent people from using ambulances to transport themselves for routine medical purposes...such as a normal labor and delivery.)

If you don't confirm in advance that you'd be covered for that ambulance ride, then you'll be responsible for the whole ambulance charge too.

You're better off arranging a support system of family, friends, and neighbors to transport you when the time comes.  (What about the child's father?)  Have all the phone numbers handy, know who's going to be available at what times for you to call.  Worst case scenario, call a taxi (if taxi service is available in your community.)  911 is not meant for regular transport of pregnant women.

Answer 3

'Emergencies' are supposed to be covered as if they were in network.  However, their definition of an emergency and your definition of an emergency are two different things.

Call the insurance company, write down who you talk to and ask them what to do in different scenarios.

I had something fall and cut my head open, so while I was bleeding I picked up the phone just to make sure I followed the right procedure and wouldn't have to pay additional dollars.

So, call the insurance company and be carefult because we went to an emergency room when my wife was pregnant and we got so frustrated that after sitting there for a half hour we got back in the car and drove across town (30 minutes away) to another hospital.

Answer 4

First, you need to take a deep breathe.  From what I am reading above you are pregnant and worked up and nervous for no reason :o)  Happens...no worries!

Many states have laws governing emergency situations in regards to insurance.  The one thing you can do is look at your policy and read the information and guidelines for emergency room visits.

Everyone's interpretation of a "true emergency" can be different.  However, if you are unconscious then you would have no control over where you were taken.  If you just went into labor though, that is not an emergency in most cases.

One thing you can do, is find out the list of hospitals from the insurance carrier that is participating with the plan you have.  To put yourself at ease, find out the ones closest to your home, work and anywhere you frequent.  Carry the list with you, so if you go into labor and you need an ambulance you can tell them the hospital or option of hospitals you can go to.  This may put your mind at ease.  For the most part though, you are only responsible for knowing the participating hospitals by your home and work.  

In most states, if you are in a "true" "life threatening" emergency and have to be rushed to the closest hospital, then you are safe and your carrier will pay.  Remember, pregnancy is not a sudden situation.  Even though labor can come in a split second, you have had time to know where the closest participating hospitals are within your "network" in case it happens quickly.

Answer 5

if you are taken to a hospital by ambulance in an emergency your HMO will cover you, especially for a birth.  there are federal laws about pregnancy.  you did not have a choice where you were going.

Answer 6

A real emergency will likely result in an abortion.  Happens all by itself, all the time.  My mother had one.  I have no idea what a site # is and not really interested.  For a regular birth, and most of them are, you set up the doctor, a friend (like me), drives like a crazed madman - intent on your safety - to your HMO doctor, who will be expecting you.

In an emergency, HMO will, in general, field the cost.  If you are not in imminent danger of losing the baby, they probably won't, and you get a crazy bill.  Mother Nature gives plenty of insured notice that you are about to have a baby.  Have a number handy, and a backup number for a different driver.

Avoid ambulance services, they are not your friend, and should anyone tell you, "You're having your baby here."  STOP everything.  Breathe and push.