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Medical Care and Plan Providers
Emergency, Urgent Care & Care Outside Service Area
Emergency Care
What is a medical emergency?
A situation is a medical emergency if you reasonably believe that your health is in serious danger . It means that every second counts. Some examples of medical emergencies are severe pain, a bad injury, a serious illness, or a medical condition that is getting worse.
What should I do if I have a medical emergency?
If you have a medical emergency:
- Get medical help as quickly as possible. Call 911 for help or go directly to the nearest emergency room. In any emergency, you never need to contact any plan provider, even your own PCP, for either permission (authorization) or referral.
- However, as soon as possible, you or someone else should contact your PCP about your emergency. Your PCP’s telephone number is located on your membership I.D. card. Your PCP needs to know about your emergency because your PCP will provide follow-up care. Please try to contact your PCP about your emergency within 48 hours.
Your PCP will help manage and follow-up on your emergency care.
It is important to know that every emergency has two stages:
When the doctors, or hospital, providing emergency care consider your condition stable, the first stage of the medical emergency ends. However, even after your condition is stabilized, you are still considered in an emergency situation and Essence must still pay for post-stabilization treatment provided by the hospital (whether or not this hospital is a plan provider or not). This second stage of the emergency, after your condition is stabilized is called "post-stabilization".
Generally, the hospital, or doctors, providing emergency care will try to talk to your PCP. This helps the plan to arrange for plan providers to take over your care as soon as your condition and circumstances get better. Once your PCP takes over your care or agrees with the attending hospital on an appropriate course of action (or once you are discharged, if you are fully recovered), you are no longer in an emergency or post-stabilization situation.
Although you are past the emergency and post-stabilization period, you may still need follow-up care. However, your plan is responsible for your follow-up care. Your plan will only pay for follow-up care after your emergency and post-stabilization, if you follow the plan rules. You will need to use plan providers to get authorizations and/or referrals.
What is covered if I have a medical emergency?
- You can get covered emergency medical care whenever you need it, anywhere in the world.
- Ambulance services are covered in situations where other means of transportation, anywhere in the world, would endanger your health.
What if it wasn't really a medical emergency?
To have your plan pay for your emergency care, you do not have to be certain that it is an emergency. For example, you might go in for emergency care - thinking that your health is in serious danger - but the doctor may disagree and not consider this a medical emergency. If this happens, you are still covered for the diagnostic treatment and care you received to determine what was wrong, provided that you thought your health was in serious danger, as explained in the section above entitled "What is a medical emergency?". However, please note that:
- If you get any extra care after the doctor says it was not a medical emergency, your plan will only pay for the extra covered care if you got this care from a plan provider.
- If you get any extra care from a non-plan provider after the doctor says it was not a medical emergency, your plan must still pay for it as urgently needed care even though you got this care outside your service area. See how "urgently needed care" is defined below.
Urgently Needed Care (This is different from a medical emergency.)
"Urgently needed care" is a non-emergency situation when you are out of the service area and you need medical attention right away for an unforeseen illness or injury, and it is not reasonable given the situation for you to wait to get medical care from plan providers. You can still get urgently needed care even if you knew about your illness or injury ahead of time, but you had an unforeseen complication.
What is the difference between a medical emergency and urgently needed care?
The difference between emergency and urgently needed care is in the seriousness of the condition. A medical emergency is when you believe your health is in serious danger, when every second counts. You may have a bad injury, sudden illness, or an illness quickly getting much worse.
Urgently needed care is care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your PCP generally provides urgently needed care. If you are out of your plan's service area for a short time and can't wait until you return to the service area, Essence will pay for urgently needed care.
Getting urgently needed care when you are in the plan's service area
If you have a sudden illness or injury that is not a medical emergency, and you are in the plan's service area, please call your PCP. There will always be a doctor on call to help you. Keep in mind that if you have an urgent need for care while you are in the plan's service area, you should get this care from plan providers. In most cases, we will not pay for urgently needed care that you get from non-plan providers while you are in the plan's service area.
Getting urgently needed care when you are outside the plan's service area
Essence covers urgently needed care that you get from non-plan providers when you are outside the plan's service area. If you need urgent care while you are outside the plan's service area, you should call your PCP. If you are treated for an urgent care condition while out of the service area, you must return to the service area to get follow-up care through your PCP for it to be covered. However, we will cover follow-up care that you get from non-plan providers outside the plan's service area as long as the care you are getting still meets the urgently needed care definition.
We also cover renal dialysis (kidney) services that you get when you are outside the plan's service area.