MEDICARE CASE FLASH: COVERAGE FOR EMERGENCY CARE

Mr. L suffers from multiple health issues, including cancer. He received a denial of coverage from his Medicare private health plan (HMO) and bills from several doctors totaling $5,000 for services that he received from February through September of last year. His plan’s Explanation of Benefits (EOB) notice stated that those doctors were not in his HMO’s network and he had not received authorization to receive care from them. Mr. L called his local State Health Insurance Assistance Program (SHIP) for help.

The SHIP counselor learned that Mr. L had originally been admitted to the hospital in February for emergency services and the services for which he had received the denial of coverage were for follow-up visits with the doctors who had treated him during the emergency. Medicare regulations mandate that both the initial emergency visit and any follow-up visits relating to the emergency must be covered by Medicare private health plans (like HMOs and PPOs), even if the providers are not in the health plan’s network. The SHIP counselor helped Mr. L appeal the denial of coverage by quoting these regulations (HCFA Regulation-HMO 2104 and 2206) and providing the plan with a copy of Mr. L’s hospital admittance notice, which states that he was there for emergency purposes. Soon after, the plan notified Mr. L that it would cover the emergency and follow-up medical services it had previously denied.

To read more cases by subject, go to "Interesting Cases" at http://www.medicarerights.org/interestingcasesframeset.html .

-Adapted from MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 10, No. 4: February 20, 2007

2/07