All health insurance plans regardless of the state of purchase will cover emergency services at any hospital in the United States, with the exception of Hawaii. However, non-emergency care, like primary care visits, might not be covered. Health emergencies and accidents can happen at any time, including during vacation or business trips. It is important to know if your health insurance will cover your care outside of your home state when traveling both domestically and internationally.
Out-of State Health Insurance Coverage
With summer vacation quickly approaching and remote jobs allowing for greater flexibility in travel, having a health insurance plan that provides out of state coverage is an essential safeguard for your health.
Every health plan regardless of city or state has a ‘network’ of healthcare providers and healthcare facilities. Generally speaking, your health plan will pay for a larger amount of the total cost when you visit in-network providers. On the contrary, if you seek care “out-of-network”, you may be faced with greater out-of-pocket costs. Furthermore, some insurance plans place restrictions on out-of-network care coverage.
Out of State Coverage by Types of Health Insurance Plans
|Type of Plan||Does it Cover Out-of-Network Care?||Additional Plan Details|
|Preferred Provider Organization (PPO)||YES|
|Health Management Organization (HMO)||NO|
|Exclusive Provider Organization (EPO)||NO|
|Point of Service Plans (POS)||YES, at an additional cost|
What to Know About Out-of-State Health Insurance Coverage
Most insurance plans restrict out-of-state coverage to emergencies and life-threatening injuries only. In the case of out-of-state emergencies, your medical expenses will be billed as ‘in-network’ regardless of the hospital you go to.
For example, If you get in a car accident and an ambulance takes you to the nearest hospital that doesn’t normally accept your insurance, you will be billed as if you were treated at an ‘in-network’ facility.
Definition of Emergency
Having your out-of-state emergencies covered can provide you with some sense of security and safety when traveling. However, one of the biggest issues is figuring out what is classified as an emergency. Most plans do not have a concrete definition of “emergency” which can lead to discrepancies between coverage.
Occasionally, insurance companies will deny claims that they deem as not a true emergency. You can file to dispute the denied claim, however, this process can be time-consuming. To know what is considered as an emergency by your health insurance plan, be sure to check your Summary of Benefits and Coverage (SBC).
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Summary of Benefits and Coverage (SBC)
Your health plan's Summary of Benefits and Coverage (SBC) will show you what is classified as an emergency by your health insurance provider. The SBC is a snapshot of your health plan’s cost, benefits, covered health services, and other features that are important to your care. The SBC also includes coinsurance, co-pay amounts, and what is considered an emergency.
You can find your SBC by googling [Plan Name +Year] SBC. For example, Oscar Health’s SBC defines an emergency as something that:
- Puts your life in serious danger (heart attack and head trauma)
- Puts you baby or children’s life in serious danger
- Puts yourself or other in serious danger (depression and schizophrenia)
- Impairs how your body functions (having a stroke)
- Caused serious disfiguration (broken nose or second degree burns)
Non-Emergency Out-Of-State Care
Any non-emergency care received outside of your home state is typically not classified as ‘in-network’ and does abide to your standard coverage or a set co-pay rates. As illustrated above, the rules and regulations on out-of-network care depend on your type of plan ( HMO, EPO, PPO, etc.).
On the contrary, some health plans have reciprocity agreements with networks outside of the designated plan parameters. This allows you to receive coverage and subsidies for out-of-state and out-of-network care. To find out if your specific plan provides some coverage with out-of-state and out-of-network care, or has reciprocity agreements with other care networks, you should call the phone number on the back of your insurance card and ask your carrier directly.
Medicaid and Medicare Out-Of-State Guidelines
Medicaid and Medicare are the primary federal government-based healthcare plans. Each program has its own set of guidelines and restrictions that dictate in- and out-of-state care options.
Medicare is federal health insurance for people 65 or older and some younger people with disabilities. Out-of-state coverage with medicare depends on when and where you travel and how you receive Medicare benefits.
If you have the Original Medicare plan, you will have coverage anywhere in the United States and respective territories - most doctors and hospitals take the original insurance. If you have a Medicare Advantage Plan, you may be faced with some restrictions. The Advantage plan may or may not cover care outside of its service area, so check with your provider before seeking out-of-state care.
Furthermore, some plans may cover providers that are out-of-network, but with higher co-pays and co-insurances. Additionally, your plan may have other restrictions such as the need for prior authorization, or referral, to use out-of-network services.
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In contrast to medicare, where everyone qualifies for the program at the age of 65, Medicaid is a federal and state program that helps lower healthcare costs for people who are classified as low income.
Because Medicaid eligibility requirements are primarily determined by the state, coverage cannot be transferred from one state to another, nor can you use the coverage when temporarily visiting another state, unless you need emergency health care.
Out-of-State Health Insurance Coverage Frequently Asked Questions (FAQs)
Below we answer some common questions about out-of-state coverage.
What is the best health insurance plan if I travel a lot?
In general, health insurance networks can vary from state to state with differing restrictions in level of insurance coverage. The best type of traditional health insurance plan with the most coverage for when you travel out of state is a PPO plan. Although PPOs have the highest cost of the four types of plans, they provide the most comprehensive coverage both in and out-of-network.
What happens to my insurance coverage if I live between two states?
If you choose not to enroll in a new plan upon leaving for your second state, your insurance will only cover emergency care, and if you want any other in-network service, you will have to return to the state you enrolled in.
The new permanent move ruling presents added difficulty for full coverage in two states. Under the recent changes made by the United States Department of Health and Human Services, you have to terminate your existing state health insurance plan and re-enroll in the second state plan each time you move. This can get very expensive, as you would be starting with a new deductible and maximum out-of-pocket each time you move.
Before Traveling out of state or internationally, figuring out what your health plan covers and what will be classified as out-of-network, is essential preparation. If you don’t prepare, and end up needed care while on a trip, paying for healthcare without insurance can result in a significant financial burden.
Although Mira does not currently offer benefits internationally, members in the United States have access to affordable care in all 50 states. Mira allows for individuals to move freely around the country with peace of mind. For an average of $45 a month Mira Members get access to low-cost urgent care visits, affordable lab testing, and discounted prescriptions. Sign up today.
Originally from Houston, Texas, Alexandra is currently getting her Master's in Public Health with a health policy certificate at Columbia University. One of her life goals is to own her own art gallery!