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Home > Emergency Care

Getting Emergency Care

Emergency room sign

 

In an emergency, you should call 9-1-1 or go to the nearest emergency room (ER).

 

 

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What is an emergency?

It is an emergency if you reasonably believe that if you don’t get care right away, it could be dangerous to your life or to a part of your body. Emergencies include active labor, a bad injury, severe pain, and an illness that is suddenly getting much worse.

 

How to get emergency care

  • If you can, go to the emergency room at a hospital in your health plan’s network.
  • Try to take your membership card with you.
  • If you are not sure if it is an emergency and there is time, call your doctor.
  • If you are admitted to a hospital outside your plan’s network, call the plan within 24 hours, or as soon as you can. Your plan may move you to a hospital in its network, if it is possible without danger to your health.

 

When can I call an ambulance?

Health plans only pay for an ambulance when:

  • You call 9-1-1 because you think you are having an emergency and cannot get to the hospital safely or quickly enough in a car.
  • Your doctor says you need an ambulance and the health plan pre-approves it.

 

How to get urgent care

Urgent care is care you need soon, usually within 24 hours, for a problem that is serious but is not an emergency. Examples include earache, a sprain, or a minor burn.

  • If you need urgent care, call your primary care doctor or health plan. Health plans must provide telephone assistance 24-hours-a-day, 7 days a week, to help you get the care you need.  The doctor or advice nurse should return your call within 30 minutes.
  • Some plans have urgent care clinics you can go to directly.
  • If you have a managed care plan, you should be able to get an appointment with your primary care doctor's office within 48 hours. If you need an urgent care appointment that requires pre-approval (such as an appointment with a specialist), you should be able to get an appointment  within 96 hours.

 

How to get care when you are away from home

Before you leave home, ask your plan how to get care when you are traveling.

  • Emergency and urgent care are usually covered anywhere in the world.
  • If you have an emergency, call 9-1-1 or go to the nearest ER.
  • If you need urgent care, call your primary care doctor or the health plan if you can. If you cannot, go to the nearest clinic or urgent care center.
  • Take your membership card with you.
  • If you need follow-up care, call your primary care doctor.

 

Problems with a bill for emergency care

  • Try not to use the emergency room if you do not need to. Your health plan may not pay for your visit if it is not an emergency. Your co-pays can be high, and your wait can be long. And it is usually better to see your own doctor, who knows your health care needs.
  • Your health plan must cover emergency care at any hospital.  If your health plan will not pay for your emergency care, you can file a complaint with your health plan.

 

Resources

Call 9-1-1 for Emergency Services (Police, Fire, or Ambulance)

Call your doctor or your health plan's 24-hour advice line if you are not sure if it's an emergency

OPA materials: How to Use Your Health Plan Guide

OPA materials: California's HMO Guide for Seniors

OPA worksheet: My Emergency Contacts

 

Related Topics

How to file a complaint

Know your benefits

Referrals and pre-approvals

Health Plan Problems?

Call 1-888-466-2219

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