Knowing if your health insurance will cover your care outside your home state is essential. People leave their state for several reasons, including vacation, work, or college students who study away from home.
Accidents and health emergencies can happen at any time. You don’t want to face costly medical bills because your insurance does not cover treatment in other states.
Regardless of the state of purchase, all health insurance plans will cover emergency services at any United States hospital except Hawaii. However, not all insurers share the exact definition of an emergency.
Moreover, your health insurance might limit non-emergency benefits when you are out of state.
This article explains what you need to know about out-of-state health insurance coverage.
What Is Out-of-state Health Insurance Coverage?
Health insurance typically restricts you to a network of healthcare providers. This is because health insurance companies negotiate discounted prices with a network of healthcare providers. So, when you take out insurance with a provider, you have to use the health professionals and facilities designated by the insurer.
If your plan specifies that you must use in-network care, then going outside the network will cost you more out of pocket or could leave you responsible for the whole bill.
Insurers negotiate costs state-by-state with a network located only in the state where the insurance policy is sold.
Most insurers do not have a nationwide network, meaning that if you visit healthcare providers in a different state, you are using out-of-network services and are responsible for full payment.
Health insurance rules and coverage details can vary by plan and location. However, emergency services are covered in every state.
Hospital care for life-threatening emergencies is billed as in-network, even if you go to a hospital that does not usually accept your insurance.
Routine care is seldom covered if it is out of state. Routine care includes non-emergency doctor check-ups.
Some states offer multi-state health insurance plans, but they are rare. Your coverage is still limited to participating states.
Some plans offer coverage for out-of-network providers when you travel to another state. But you are likely to have higher co-pays and deductibles.
Types Of Health Insurance Plans With Out-of-state Coverage
While there are various types of health insurance plans, the two that provide some out-of-state coverage include Preferred Provider Organizations and Point of Service Plans.
PREFERRED PROVIDER ORGANIZATION
Preferred provider organizations (PPOs) have a network of providers they prefer you use. Still, they do allow for out-of-network care.
PPOs do not dictate that you have to see a primary care physician in order to be referred for specialty services.
Less restrictive health insurance, like PPOs, tends to have higher monthly premiums and sometimes requires higher cost-sharing. In recent years, PPOs have become less available as insurers reduce the size of their provider networks to minimize costs.
POINT OF SERVICE PLANS
Point of service (POS) plans usually offer some coverage for out-of-network care. Still, these plans require you to get specialist referrals from primary care doctors.
Some health insurers have reciprocal agreements with out-of-state networks. This means you can receive some out-of-state and out-of-network care.
To find out if your insurance carries a reciprocity agreement, you need to contact your health insurance carrier directly.
What To Know About Out-of-state Health Insurance Cover
Here are some important things to know about out-of-state health insurance.
What Counts As An Emergency?
While your health insurance plan covers out-of-state emergencies, it’s essential to clarify what your insurance defines as an emergency.
The Summary of Benefits and Cover in your health plan will outline what your insurer classifies as an emergency.
Many people find themselves out of pocket when the insurer decides the case is not an emergency.
An emergency generally includes:
- An incident that puts your life in danger, such as a heart attack or a head trauma.
- An illness or accident that puts your baby’s life in danger if you’re expecting.
- A mental illness that puts your or others’ lives in danger, such as depression or schizophrenia.
- An accident or illness that impairs how your body functions, for example, a broken limb or a stroke.
- An accident that disfigures you, for example, burns or severe lacerations.
Only Urgent Care Is Covered
Emergency cover is only applicable until you are stable. Out-of-state insurance does not cover continued services, even related to the emergency.
For follow-up care like physical therapy or follow-up appointments, you must return to your network area for care, or you will be responsible for the payment.
Non-Emergency Out-of-state Care
Generally, plans are not required to cover care from a non-network provider. Care received outside your home state is typically out-of-network and does not form part of your standard health insurance coverage.
However, whether you have any non-emergency out-of-state cover will depend on the rules of your type of insurance and plan.
Prescription Drug Coverage
You can fill your drug prescription out of state using the same in-network pharmacy chain. If you use a chain pharmacy such as Walmart, look for a nearby store when you are away from home.
Using a chain pharmacy does not require transferring your prescription if you travel out of state.
Medicare, the federal insurance for people over 65 or people with disabilities, does offer out-of-state coverage. Still, it depends on how you receive Medicare benefits and when and where you travel.
The Original Medicare plan offers coverage throughout the United States. Most healthcare facilities and doctors accept the original insurance.
You may face some restrictions if you have a Medicare Advantage Plan. Some Advantage plans only cover care in a specific service area. Your plan may also require pre-authorization for treatment or have higher co-pays for out-of-network cover.
Frequently Asked Questions About Out-of-State Health Insurance Coverage
How can I get health insurance coverage when out of state?
There are several ways you can get health insurance coverage if you travel out of state.
- Supplemental coverage is an add-on to your existing coverage. You can take out accidental or critical illness cover that will provide money if you become ill or experience an accident. Supplemental coverage with pay regardless of location or network. You can also take out a hospital indemnity plan that will pay for hospital stays and doctor visits with a nationwide network.
- Short-term health plans provide temporary coverage when there is a lapse in your permanent coverage. For example, when you change jobs, attend college out of state, or move to another state.
- Travel insurance plans include unexpected medical expenses that occur when you travel. You can tailor travel insurance to give you adequate coverage during out-of-state trips.
What happens to my insurance coverage if I live between two states?
Living between states can prove challenging and expensive regarding health insurance. You cannot take out cover in two different states simultaneously.
According to the United States Department of Health and Human Services, you must terminate your existing health insurance coverage each time you move states and enroll in a new plan applicable in the state you move to.
If you choose not to enroll in a new plan, your health insurance will cover nothing but emergency care in your new state.
Can I stay on my parent’s health insurance if I move out of state?
Parents’ health plans cover children as dependents till they are 26. However, if your plan does not have network providers in your new state, you will only have health insurance coverage for emergencies.
Moving to another state for college qualifies you for a Special Enrollment Period to enroll in a new cover. It may be worthwhile chatting with an insurance agent to discuss your options.
If you are traveling out of state, whether on vacation or for work, you want peace of mind that your health insurance covers you for any medical eventuality.
If your health insurance does not include out-of-state coverage, buying supplemental coverage, such as medical travel insurance, might be necessary.
The terms of your health insurance policy will detail precisely what medical treatments are covered out of state. However, sifting through the fine print can be confusing and frustrating. If you need help finding out-of-state health coverage, give Enhance Health a call today.
Our experienced agents will help you understand the fine print and explain your options for medical coverage while you visit another state.