Medicare Advantage: HMO Special Rules

Your Medicare Advantage Plan must provide access to Emergency and Urgently Needed Care services 24 hours a day, 7 days a week.

If an event happens, it is advisable to take a moment to think about whether the emergency seems to be life threatening or not.

If the emergency seems to be life threatening

• Seek help anywhere immediately. Do not waste time trying to get to a network facility if emergency care is available closer. The Medicare Advantage Plan must cover it as long as you receive emergency care anywhere in the United States.
• If it turns out that the situation was not life threatening, the Plan must still pay for the costs as long as you reasonably believed that it was. For example: you have chest pains while on vacation. Thinking it may be a heart attack, you call 9-1-1. Even if it turns out to just be the spicy dish you had for dinner causing the discomfort, the Medicare Advantage Plan must still pay.

If the emergency is Urgently Needed Care

• If you are within your Plan's service area, you are expected to go to a network facility for care, unless your Plan instructs you to do otherwise.
• Your Plan must pay for "Urgently Needed Care" provided outside the network if you are temporarily out of the Plan's service area and cannot wait until you return. 

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