Emergency room benefit for New Hampshire plans

What you pay will depend on the reason for your visit

Starting with 2019 plan effective dates, most members on our New Hampshire plans will pay higher cost sharing for emergency room (ER) visits that are not considered medical emergencies.

Higher cost sharing for non-emergency diagnoses

We will not deny any claims based on the reason for your ER visit, but if you go to the ER and your diagnosis falls into one of the following categories, you may pay higher cost sharing than you will for an emergency diagnosis. In most cases, for non-emergency diagnoses, you will pay the deductible then 50% coinsurance (after any negotiated discounts). If you are charged higher cost sharing for a service that you believe was a true medical emergency, you can contact Member Services to appeal our decision.

• Respiratory infections (e.g., common cold, cough or bronchitis without shortness of breath or blood)
• Viral infections (e.g., common cold, cold sores or genital rash)
• Fungal infections (e.g., athlete’s foot, jock itch or yeast infections)
• Immunizations and screening for infectious diseases
• Sprains and strains
• Minor joint injuries and dislocations
• Crushing injury or internal injury routine follow-up
• Superficial injuries, such as contusions, abrasions and insect bites
• Subsequent or routine follow-up care for open wounds
• First degree burns
• Rashes
• Minor ear conditions (e.g., impacted ear wax or swimmer’s ear)
• Minor eye disorders (e.g., styes, dry eye or pink eye without vision loss)
• Diseases of mouth; excluding dental (e.g., cold sores or canker sores)
• Routine follow-up and care for fluid and electrolyte disorders
• Routine follow-up and care for diseases of the veins and lymphatics
• Routine follow-up and care for liver disease
• Routine follow-up and care for thyroid disorders
• Routine follow-up and care for obstructive pulmonary disease and bronchiectasis
• Screening of mental health and substance abuse use disorders
• Treatment for dementia, amnesia and other cognitive disorders when not associated with acute changes or event like stroke
• Non-cancerous tumor/mass/tissue
• Routine pre-natal and postpartum care 
• Physical exams
   

Please note that any examples provided above are for clarification purposes only and do not constitute an exhaustive list of diagnoses that may be considered non-emergency diagnoses.

Regular cost sharing for emergency diagnoses

You will pay the regular emergency room member cost sharing (e.g., deductible then copayment) when you visit the ER for conditions that are considered medical emergencies. These are generally injuries and illnesses that are severe or life-threatening, such as a heart attack, severe head trauma, major bleeding, convulsions, or loss of consciousness. Refer to your Benefit Handbook and Schedule of Benefits for specific coverage information. These documents are available by logging in to your member account and clicking “View My Plan Documents” under “Plan Details.”

Alternatives to the ER

Urgent care centers, retail clinics and telemedicine services are also some care options to consider when you can’t be seen at your primary care provider’s office right away. These alternatives typically have shorter waits and will cost you less than an ER visit.