To help reduce emergency room (ER) overuse for the treatment of injuries and illnesses that aren’t severe or life-threatening, Harvard Pilgrim is introducing a new member cost sharing structure for ER visits for our New Hampshire (NH) commercial plan members.
Currently, NH members pay the deductible and copayment for any ER visit. While that still applies for emergent conditions, starting on Jan. 1, 2019, NH plan members treated at an ER for non-emergent conditions are responsible for the deductible and 50% coinsurance after the deductible has been met. This change will apply for most, but not all, NH employer groups; members of commercial NH plans who are affected by this change will receive new ID cards with the updated cost sharing information.
Harvard Pilgrim will not deny ER claims due to this benefit change.
The new ER cost sharing structure applies for non-emergent diagnoses billed in the primary position and is relevant for diagnoses in approximately 25 categories, with the most common examples being:
- respiratory infections
- sprains and strains
- superficial injury; contusion
- ear conditions
- physical exam
Please refer to the complete list of diagnosis codes for which the higher ER copay would apply for additional information.