Emergency Room visits are always In-Network, but prepare your clients for what happens next

When a medical emergency strikes, the last thing your health insurance clients should be worried about is whether the hospital is in-network. And thankfully, they don’t have to — at least at first.

Federal laws like the Affordable Care Act, the No Surprises Act, and EMTALA ensure that care for emergent, life-threatening conditions is always billed as in-network, even if the hospital or doctors they see don’t normally accept their insurance.

That’s the good news.

But there’s a second part to the story — and it’s where many patients unknowingly end up with out-of-network bills. Let’s break it down.

What counts as an emergency?

An “emergency medical condition” is defined as anything that a reasonable person would believe needs immediate attention to avoid serious harm. That includes:

• Chest pain or signs of a heart attack

• Difficulty breathing

• Sudden loss of consciousness

• Severe bleeding

• Stroke symptoms

• Serious injuries or trauma

In these situations, your clients should always go to the nearest emergency room. The law protects them during this critical window.

The catch: Post-stabilization care

Here’s where things get tricky.

Once the condition is stabilized — meaning they're no longer in immediate danger — the hospital may transition the patient to post-stabilization care. This could include:

• Staying overnight or being admitted for observation

• Getting additional scans or procedures

• Seeing a specialist

• Being transferred to another facility

At this stage, the law no longer requires that care be treated as in-network. And unless they’re careful, your clients could end up on the hook for out-of-network charges without realizing it.

When and how can hospitals ask patients to pay for out-of-network care?

Hospitals may ask your clients to sign paperwork that includes notices and consents related to receiving out-of-network post-stabilization care, and there are some conditions about when they can do so:

• Your client must be in a condition to give informed consent
• The notice and consent form must be given separately from other documents, not bundled or buried with other paperwork
• The form must be given to your clients in the way they prefer, whether printed or emailed
• The form must be made available in any of the 15 most common languages in the state where care was rendered
• The form must be given in advance of receiving care, though timing requirements vary depending on when care is scheduled

What should your health insurance clients ask before they sign?

Before signing a notice or consent form, your clients should:

• Ask: “Is this facility in my insurance network?”

• Confirm whether any specialists they’ll see (like a surgeon, anesthesiologist, or radiologist) are also in-network.

• If they’re not, ask if they can transfer to an in-network hospital or provider.

• Not sign consent forms agreeing to out-of-network charges unless you fully understand what they mean.

This doesn’t mean your clients should delay necessary care, but it does mean that once they're stable, it’s smart to pause and check.

What your clients can do now to avoid surprise bills

1. Know their preferred hospitals. Check now which emergency rooms and facilities are in-network with their plan.

2. Call you, their trusted health insurance agent. Carriers' find-a-provider tools can help you verify network status or find a plan that includes the hospitals your clients trust.

3. Stay informed. Knowing how post-emergency care works helps them avoid unnecessary expenses later.

Questions about your clients' coverage?

If you’re unsure whether a plan includes the hospitals or specialists your clients prefer to see, give us a call. We'll search the right provider directories, confirm network status, and help you look like a rockstar in front of your clients.