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Medicare Advantage: HMO Special Rules

Emergency Care

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Because of past problems some members had getting their HMO to pay for emergency care provided outside their network, the federal government has created a "prudent layperson" definition of an emergency that the HMO must cover whether you have the emergency in the area the HMO covers or everywhere else in the U.S.

A Medical Emergency includes severe pain, an injury, sudden illness, or suddenly worsening illness that you believe may cause serious danger to your health if you do not get immediate medical care.

Examples of emergencies include:

  • Chest pains or other symptoms that could indicate a heart attack.
  • Severe or uncontrolled bleeding.
  • Severe abdominal pain.
  • An accident that causes pain to a limb that might be broken.
  • Unexplained severe headache.
  • A cut or piercing of the skin to the extent that stitches may be required to close it.

Examples of what would (probably) not be emergencies include:

  • Sore throat.
  • Small cut.
  • Congestion due to cold or flu.
  • Upset stomach.

Any of these, if severe enough or associated with a known serious condition, could be a covered emergency. 

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