HMO plans: Getting emergency care anywhere

A medical emergency is a medical problem so serious that you have to get care right away or you could be permanently disabled or die.

Wherever you are, get help immediately 

All care needed to treat a medical emergency will be covered, whether or not you are in the Priority Health service area or the emergency room is in your provider network. BUT: 

• If you go to an emergency room and it's not a medical emergency, your plan won't pay for the visit.
• When you get emergency care services from a provider who's not in your plan's network, your plan will only pay the "reasonable and customary" cost of those services. The provider might bill you for the difference.

Then call your PCP

Call your primary care doctor or other primary health care provider's (PCP's) office as soon as possible, or have someone call for you if you are hospitalized. 

• Your PCP MUST coordinate any follow-up and continuing care. 
• Any follow-up care provided by an out-of-network provider must be pre-approved by Priority Health to be covered.
• If you are hospitalized and your stay is no longer a medical emergency, Priority Health must approve your inpatient stay for the cost to be covered by your plan. Once you are stabilized Priority Health may require that you be transferred to an in-network facility.

Some examples of emergencies

• Injury to eyes or ears
• Trouble breathing after taking medication or being bitten by an insect
• A broken bone
• Chest or upper stomach pain
• Coughing up or throwing up blood
• Pain in the chest and one arm
• Bleeding that won't stop
• Poisoning or drug overdose
• Seizure
• Sudden dizziness or weakness
• Slurred speech
• Sudden difficulty seeing