Does Obamacare Cover Out-of-State Care?

If you have health insurance through the Affordable Care Act (ACA), also known as Obamacare, you may wonder if your coverage extends to out-of-state care. The answer is that it depends on your plan type, network, and situation. Here are some of the main factors that affect your out-of-state coverage under Obamacare.

Key Takeaways:

• Your plan type, network, and situation determine how much and what kind of out-of-state care you can access under Obamacare.
• HMOs and EPOs usually do not cover any out-of-network care, except for emergencies or urgent care, while PPOs and POS plans usually cover some out-of-network care, but at a higher cost.
• Some plans have regional or national networks that include providers in other states, while others have local networks that only include providers in your state or area.
• You should always check with your plan and the provider before getting any out-of-state care to confirm your coverage and costs.

Plan Type

The type of plan you have can determine how much and what kind of out-of-state care you can access. Generally, there are four types of plans available through the Health Insurance Marketplace:

• HMO (Health Maintenance Organization): This is a type of plan that requires you to get your care from a network of providers that contract with the plan. You usually need a referral from your primary care provider (PCP) to see a specialist. HMOs typically do not cover any out-of-network care, except for emergencies or urgent care. This means that if you travel or move to another state, you may have to pay the full cost of any non-emergency or non-urgent care you receive there.
• PPO (Preferred Provider Organization): This is a type of plan that allows you to get your care from any provider, but gives you lower costs if you use providers in the plan’s network. You do not need a referral from your PCP to see a specialist. PPOs usually cover some out-of-network care, but at a higher cost than in-network care. This means that if you travel or move to another state, you may be able to get some non-emergency or non-urgent care there, but you will pay more for it.
• EPO (Exclusive Provider Organization): This is a type of plan that combines some features of HMOs and PPOs. It requires you to get your care from a network of providers that contract with the plan, but does not require a referral from your PCP to see a specialist. EPOs typically do not cover any out-of-network care, except for emergencies or urgent care. This means that if you travel or move to another state, you may have to pay the full cost of any non-emergency or non-urgent care you receive there.
• POS (Point of Service): This is a type of plan that also combines some features of HMOs and PPOs. It requires you to get a referral from your PCP to see a specialist, but allows you to get your care from any provider, with lower costs if you use providers in the plan’s network. POS plans usually cover some out-of-network care, but at a higher cost than in-network care. This means that if you travel or move to another state, you may be able to get some non-emergency or non-urgent care there, but you will pay more for it.

You can check your plan type by looking at your plan ID card, your plan documents, or your Marketplace account. You can also contact your plan directly to ask about your out-of-state coverage options.

Network

The network of providers that contract with your plan can also affect your out-of-state coverage. Some plans have regional or national networks that include providers in other states, while others have local networks that only include providers in your state or area. You can check your plan’s network by looking at your plan’s provider directory, which should be available online or by request. You can also contact your plan directly to ask about your network size and scope.

If your plan has a regional or national network that includes providers in other states, you may be able to get in-network care when you travel or move to another state, as long as you use those providers. However, you should be aware that not all providers in other states may be in your network, and that your network may change over time. Therefore, you should always verify with your plan and the provider before getting any out-of-state care.

If your plan has a local network that only includes providers in your state or area, you may not be able to get in-network care when you travel or move to another state, unless it is an emergency or urgent situation. In this case, you may have to pay the full cost of any non-emergency or non-urgent care you receive there, or look for another plan that covers out-of-state care.

Situation

The situation in which you need out-of-state care can also affect your coverage. Generally, there are three types of situations:

• Emergency: This is a situation in which you have a serious medical condition that requires immediate attention and could result in death or serious harm if not treated right away. Examples include chest pain, severe bleeding, stroke, or poisoning. In this case, you should go to the nearest hospital or call 911, regardless of your plan type or network. All Obamacare plans are required to cover emergency care at the same level, whether it is in-network or out-of-network, and whether it is in-state or out-of-state. However, you may still be responsible for some costs, such as deductibles, copayments, coinsurance, or balance billing.
• Urgent: This is a situation in which you have a medical condition that requires prompt attention but is not life-threatening. Examples include fever, infection, sprain, or minor injury. In this case, you should try to find an in-network provider or facility in your area, if possible. If not, you may be able to get out-of-network care at a lower cost than non-urgent care, depending on your plan type and network. However, you may still be responsible for some costs, such as deductibles, copayments, coinsurance, or balance billing.
• Non-urgent: This is a situation in which you have a medical condition that does not require immediate or prompt attention and can be scheduled in advance. Examples include routine check-ups, preventive services, elective procedures, or chronic care. In this case, you should try to get your care from an in-network provider or facility in your state, if possible. If not, you may have to pay the full cost of any out-of-network care, depending on your plan type and network. Alternatively, you may want to consider changing your plan or applying for a special enrollment period if you move to another state permanently.

You should always check with your plan and the provider before getting any out-of-state care to confirm your coverage and costs.

Conclusion

Obamacare does cover out-of-state care, but the extent and cost of your coverage may depend on your plan type, network, and situation. You should always review your plan details and contact your plan directly to ask about your out-of-state coverage options and costs. You should also be prepared to pay some out-of-pocket expenses for any out-of-network or out-of-state care you receive.