Question and Answer
Medicare Advantage plan coverage of out-of-network emergency care.
Do I need a referral for an emergency visit if I am in a Medicare Advantahe plan?
All Medicare private health plans (like HMOs or PPOs) must allow you to get emergency care whenever you need it from any provider in the United States. You do not need to get a referral from your primary care doctor or permission from your plan first.
A medical emergency is when you believe that your health is in serious and immediate danger. You may have a bad injury, a sudden illness or an illness that is quickly getting much worse. For example, if you have chest pains that feel like a heart attack.
Your health plan must pay for the emergency services even if your condition, which appeared to be an emergency, turns out not to be one (for example, if the chest pain you thought was a heart attack turned out to be heart burn). Coverage must continue until you are stabilized. If your plan does not pay for your emergency care, you have the right to appeal. (Note: for non-network emergency care, the plan can charge you the in-network co-pay or $65 in 2013).
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