Emergency & Urgent Care (2024)

What is a medical emergency?

Amedical emergencyis a medical condition with symptoms such as severe pain or serious injury. The condition is so serious that, if it doesn't get immediate medical attention, you or any prudent layperson with an average knowledge of health and medicine could expect it to result in:

• Placing the person's health in serious risk;or
• Serious harm to bodily functions;or
• Serious dysfunction of any bodily organ or part;or
• In the case of a pregnant woman, an active labor, meaning labor at a time when either of the following would occur:
  • There is not enough time to safely transfer the member to another hospital before delivery.
  • The transfer may pose a threat to the health or safety of the member or unborn child.

What should you do if you have a medical emergency?

If you have a medical emergency:

• Get help as fast as possible.Call 911 or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
• As soon as possible, make sure that our plan has been told about your emergency.We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. Contact Member Services at 1-855-464-3571 (TTY: 711) for Los Angeles County and 1-855-464-3572 (TTY: 711) for San Diego County. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.

What is covered if you have a medical emergency?

You may get covered emergency care whenever you need it, anywhere in the United States or its territories. If you need an ambulance to get to the emergency room, our plan covers that. To learn more, see the Benefits Chart in Chapter 4of the Member Handbook.

For members enrolled in Los Angeles County, you may get covered emergency medical care outside the United States. This benefit is limited to $50,000 per year. For more information, see “Worldwide Emergency/Urgent Coverage” in the Benefits Chart in Chapter 4 of the Member Handbook.

For members enrolled in San Diego County, coverage is limited to the United States and its territories: the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

There are some exceptions under Medicare as follows:

There are three situations when Medicare may pay for certain types of health care services you get in a foreign hospital (a hospital outside the U.S.):

1. You're in the U.S. when you have a medical emergency, and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury.
2. You're traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as "without unreasonable delay" on a case-by-case basis.
3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether it's an emergency. In these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.

Medi-Cal coverage is limited to the United States and its territories, except for Emergency Services requiring hospitalization in Canada or Mexico.

After the emergency is over, you may need follow-up care to be sure you get better. Your follow-up care will be covered by us. If you get your emergency care from out-of-network providers, we will try to get network providers to take over your care as soon as possible.

What if it wasn't a medical emergency after all?

Sometimes it can be hard to know if you have a medical emergency. You might go in for emergency care and have the doctor say it wasn't really a medical emergency. As long as you reasonably thought your health was in serious danger, we will cover your care.

However, after the doctor says it wasnotan emergency, we will cover your additional careonlyif:

• You go to a network provider,or
• The additional care you get is considered "urgently needed care" and you follow the rules for getting this care. (See the next section.)

Getting urgently needed care

What is urgently needed care?

Urgently needed careis care you get for a sudden illness, injury, or condition that isn't an emergency but needs care right away. For example, you might have a flare-up of an existing condition and need to have it treated.

Getting urgently needed care when you are in the plan's service area

In most situations, we will cover urgently needed careonlyif:

• You get this care from a network provider,and
• You follow the other rules described in this chapter.

However, if you can't get to a network provider, we will cover urgently needed care you get from an out-of-network provider.

In serious emergency situations: Call "911" or go to the nearest hospital.

If your situation is not so severe: Call your PCP or Medical Group or, if you cannot call them or you need medical care right away, go to the nearest medical center, urgent care center, or hospital.

If you are unsure of whether an emergency medical condition exists, you may call your Medical Group or PCP for help.

Your Medical Group is available 24 hours a day, seven days a week, to respond to your phone calls regarding medical care that you believe is needed immediately. They will evaluate your situation and give you directions about where to go for the care you need.

If you are not sure whether you have an emergency or require urgent care, please contact a clinician by calling our Nurse Advice Line, 24 hours a day, 7 days a week at:

• Los Angeles County: 1-855-464-3571 (TTY: 711)
• San Diego County: 1-855-464-3572 (TTY: 711)

Getting urgently needed care when you are outside the plan's service area

When you are outside the service area, you might not be able to get care from a network provider. In that case, our plan will cover urgently needed care you get from any provider.

For members enrolled in Los Angeles County, urgently needed services received outside of the United States may be considered an emergency under the worldwide emergency/urgent coverage benefit. For more information, see “Worldwide Emergency/Urgent Coverage” in the Benefits Chart in Chapter 4 of the Member Handbook.

For members enrolled in San Diego, our plan does not cover urgently needed care or any other care that you get outside the United States.

Out-of-Network Coverage

In most cases, you must receive your care from aHealth Net Cal MediConnect provider. There are some exceptions, however, when care you receive from an out-of-network provider will be covered. Those exceptions are:

• Emergency care or urgently needed care that you get from an out-of-network provider
• If you need care that cannot be adequately provided by a network provider, including need for continuity of care, you can get this care from an out-of-network provider.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area
• The plan covers out-of-network care in unusual circ*mstances, so long as those services are authorized in advance by your primary care provider or Health Net Cal MediConnect. Please remember that without that authorization, you will be responsible for payment of the service.

Examples of unusual circ*mstances that may lead to out-of-network care are:

• You have a unique medical condition and the services are not available from network providers.
• Services are available in-network but are not available as soon as you need them
• Your primary care provider determines that a non-network provider can best provide the service.