Medihelp: Emergency Room Insurance Coverage?

In South Africa, Medihelp is a medical aid cover that provides coverage for medical emergencies. If you require treatment for a medical emergency as defined in the Medical Schemes Act, the treating doctor will certify the condition, and Medihelp will approve it as a prescribed minimum benefits (PMB) condition. However, if your condition does not qualify as a medical emergency, your treatment will be considered a visit to a GP's emergency room, and you will be responsible for any facility fees charged by the emergency unit.

Medihelp covers medical emergencies as defined in the Medical Schemes Act

Medihelp provides comprehensive cover for medical emergencies, as defined by the Medical Schemes Act. This includes unlimited cover for ambulance services and treatment of medical emergencies.

The Medical Schemes Act defines a medical emergency as:

> the sudden and unexpected onset of a health condition that requires immediate medical and/or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.

If you require treatment at an emergency unit for a medical emergency, the treating doctor will certify the condition as a medical emergency, and Medihelp will approve it as a prescribed minimum benefits (PMB) condition.

In the event of an emergency hospital admission, you must register the emergency on the first workday after the admission by calling Medihelp's Customer Care centre on 086 0200 678. You will need to provide the following information:

• Details of the patient, hospital and doctor
• Diagnostic and procedure codes
• Admission date and time

If your condition does not qualify as a medical emergency, and you do not require life-saving treatment or admission to the hospital, the treatment you receive will be viewed as a visit to a GP’s emergency room. In this case, Medihelp will cover the consultation fee from the available benefits of your medical aid plan, but any facility fees charged by the emergency unit will not be covered.

If your condition doesn't qualify as a medical emergency, you will be liable for the consultation fee and any additional fees

If your condition does not qualify as a medical emergency, you will be liable for the consultation fee and any additional fees. This means that you will be responsible for covering the cost of the visit yourself, and it will not be covered by your insurance plan.

In this case, it's important to understand the difference between a medical emergency and a non-emergency. A medical emergency is typically defined as a sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment. If failure to provide such treatment would result in serious impairment to bodily functions, serious dysfunction of a bodily organ, or place the person's life in serious jeopardy, it is considered an emergency.

On the other hand, a non-emergency condition is one that is not life-threatening and does not require immediate medical attention. Examples of non-emergency conditions include moderate symptoms of illness, minor physical injuries, or small wounds that may need stitches.

If you visit an emergency room and are not admitted to the hospital, your insurance company may consider your visit a non-emergency. In this case, you will be responsible for the consultation fee and any additional charges, such as facility fees, medication costs, or after-hours fees.

To avoid unexpected expenses, it is recommended that individuals evaluate their medical situation and consider alternative options such as urgent care centres or telemedicine services for non-emergency issues. These alternatives can provide similar treatment at a lower cost and with shorter wait times.

Additionally, it is important to understand your insurance coverage and whether the facility you are visiting is in-network or out-of-network. Out-of-network providers may result in higher costs and unexpected bills.

By understanding the difference between emergencies and non-emergencies, and by carefully considering your treatment options, you can help minimise unexpected financial liabilities.

If admitted to the hospital for treatment, Medicare Part A will cover your ER visit

In the context of insurance, a medical emergency is defined in the Medical Schemes Act as "the sudden and unexpected onset of a health condition that requires immediate medical and/or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy".

Medihelp does cover medical emergencies. If you require treatment at an emergency unit for a medical emergency, the treating doctor will certify the condition as a medical emergency, and Medihelp will approve it as a prescribed minimum benefits (PMB) condition.

Now, if you are admitted to the hospital for treatment, Medicare Part A will cover your ER visit. This is because Medicare Part A is sometimes called "hospital insurance", and it covers the costs of an emergency room (ER) visit if you are admitted to the hospital to treat the illness or injury that brought you to the ER.

If your ER visit isn’t covered under Medicare Part A, you may be able to get coverage through Medicare Part B, C, D, or Medigap, depending on your specific plan. Medicare Part B is sometimes used to cover ER visits where the patient is not admitted or is only kept for one night for observation.

Medicare Part B generally pays 80% of your costs. You are responsible for the remaining 20%. In 2022, the annual Part B deductible was $233. You will also owe copayments for each service received.

Medicare Part C (Medicare Advantage) plans also pay for ER and urgent care expenses. Even though Medicare Parts B and C usually pay for ER visits, you’ll still be responsible for your deductible, coinsurance, and copayments in addition to your monthly premiums for these plans.

If you have Medigap (Medicare supplement insurance) in addition to your Part B plan, it can help you pay your 20% of the cost of the ER visit.

Medicare Part B and Medicare Advantage plans usually cover 80% of the cost of ER services

In the context of insurance, a medical emergency is defined in the Medical Schemes Act as "the sudden and unexpected onset of a health condition that requires immediate medical and/or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy".

In the United States, Medicare Part B and Medicare Advantage plans usually cover 80% of the cost of emergency room (ER) services. This means that patients are responsible for the remaining 20% in the form of coinsurance, copayments, and deductibles. It's important to note that Medicare Part B is also known as "Medical Insurance" and is distinct from Medicare Part A, which is "Hospital Insurance". While Medicare Part A covers inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care, Medicare Part B covers services from doctors and other healthcare providers, durable medical equipment, and many preventive services.

Medicare Advantage, also known as Part C, is a Medicare-approved plan offered by private companies that provides an alternative to Original Medicare for health and drug coverage. These "bundled" plans typically include Part A, Part B, and Part D (drug coverage). They may offer additional benefits not covered by Original Medicare, such as vision, hearing, and dental services.

In the case of Medihelp, it is confirmed that they do cover medical emergencies as defined in the Medical Schemes Act. If a doctor certifies that your condition meets this definition, Medihelp will approve it as a prescribed minimum benefits (PMB) condition. However, if your condition does not qualify as a medical emergency, your treatment will be considered a visit to a general practitioner's (GP) emergency room, and you will be responsible for any facility fees charged by the emergency unit.

You don't need to call your insurer in a true emergency — go straight to the hospital

In a true emergency, your priority should be to get to the hospital as soon as possible. You do not need to call your insurer for prior approval before seeking emergency room services, even if the hospital is outside your insurance plan's network. This is because, by law, hospitals are required to treat you regardless of your insurance status.

In the US, the Emergency Medical Treatment and Labor Act (EMTALA) mandates that anyone who goes to the ER must be stabilised and treated, even if they are uninsured and it is unclear how they will pay for treatment. The Affordable Care Act (ACA) also requires all ACA-compliant health insurance plans to cover emergency services.

However, it is important to note that not all health insurance plans cover emergency care. Therefore, it is advisable to check the details of your specific plan. Additionally, while you won't be denied treatment, you may still be liable for certain costs, depending on your insurance plan and the hospital you visit. For example, you may be subject to a deductible, or the hospital may have specific rules regarding payments.

If you are experiencing any of the following symptoms, you should seek immediate care at the nearest hospital:

• Signs of a stroke, such as slurred speech, weakness on one side, or drooping of the face
• Signs of a heart attack, such as chest pain, shortness of breath, dizziness, sweating, or vomiting
• Symptoms of dehydration, including a fast heart rate, dizziness, muscle cramps, and intense thirst
• Head injury with passing out, fainting, or confusion
• Injury to the neck or spine, especially with a loss of feeling or inability to move
• Electric shock or lightning strike
• Severe chest pain or pressure
• Seizure lasting more than one minute or from which the person does not rapidly awaken
• Sudden inability to speak, see, walk, or move
• Sudden weakness or drooping on one side of the body
• High fever with a headache and stiff neck
• Poisoning or overdose of drugs or alcohol

In non-life-threatening situations, it is worth considering visiting an urgent care clinic instead of the ER. Urgent care clinics are typically less expensive and have shorter wait times. They can handle many issues that do not require emergency treatment, such as minor wounds, cuts, minor physical injuries, and mild illnesses.

Frequently asked questions