Whether you’re going on a cross-country road trip or just visiting family in the next state over, if you happen to need medical care while away from home, you will likely wonder, “Can I use my health insurance in another state?”
The short answer is that this will depend on the insurance plan type you have. Some plan types, like PPO or OAP plans, allow for full access to any and all participating providers in that carrier’s network, regardless of which state you reside in. Other plan types, like HMO or POS plans, will cover emergency services anywhere in the country but may not cover routine care in another state.
As such, before you head out of state, make sure you understand when you can and cannot use your existing coverage. Let’s break down how you can find out what your insurance plan covers.
How Do Health Insurance Plans Determine What Care Is Covered?
To better understand whether your health insurance will work in another state, it is essential to understand how insurance companies determine what types of care they pay for.
In order to keep their costs down, most health insurance companies have what is referred to as a “network” of providers, which are typically all located within a certain radius of where you live.
Just because a provider is close to you, however, doesn’t mean they are automatically in-network as well, so it’s always wise to check with the doctor you plan to see before booking an appointment.
Not all provider networks work the same way, either. Here are some common health insurance network types:
Preferred Provider Organization (PPO) or Open Access Plus (OAP): You pay less if you use in-network providers — you won’t need a referral to see out-of-network providers (including those in other states), but you will need to pay more
Health Maintenance Organization (HMO): Coverage is limited to in-network providers (typically those you live or work close to), and it usually won’t cover out-of-network care at all except in emergency situations
Exclusive Provider Organization (EPO): Only covers in-network care, except in emergencies
Point of Service (POS): You pay less if you see in-network providers, but you’ll need a referral to see a specialist
The monetary amount your plan covers will typically vary based on its coverage level. Plans offered through the Health Insurance Marketplace (often informally referred to as “Obamacare”) come in “platinum,” “gold,” “silver,” and “bronze” levels.
Platinum and gold plans tend to cover more and have lower deductibles and out-of-pocket maximums, but they involve higher monthly premiums. Bronze plans cost less each month, but they often cover less and have higher deductibles and out-of-pocket maximums, while silver plans sit somewhere in the middle.
What’s Covered if You Use Your Plan in Another State?
For PPO and OAP plans, if there are participating providers in the insurer's national network, the plan will pay for the out-of-state care at the in-network level. It doesn't have to be an emergency. It’s best to verify network coverage through the insurer's website or by calling the insurer directly.
For HMO and POS insurance plans, however, most out-of-state care is seen as out-of-network care, so your insurance plan will typically not cover it. The exception is emergency care, which is almost always billed as “in-network.”
If you’re traveling in another state and you get in a very bad car accident, for instance, you’ll be taken to a hospital that ordinarily would not accept your insurance, but given that you need emergency care, that hospital visit would be billed as in-network.
However, there is a caveat at play. Insurance companies may have different definitions of what constitutes an “emergency.” In some cases, your insurance company may deny the claim because it simply deems your circumstances as “not an emergency.”
Fortunately, you do have some recourse if that happens. You can appeal the denial with your insurance company. It’s a process that can be tedious and time-consuming, but it’s ultimately worthwhile, especially if you’re faced with a large out-of-network bill.
How Do You Know What Your Coverage Will Be Before Traveling to Another State?
The best way to know whether your coverage will work in another state is by looking through your evidence of coverage (EOC) document, which your insurance company will issue to you each year when your coverage begins. The document goes into detail regarding what costs your insurance covers and how much you’ll need to pay for different services as well as what your policy won’t cover.
Your EOC should very clearly state what types of out-of-state care it will cover, but most are very detailed and complex. If you’re having trouble understanding what types of out-of-state care are covered, don’t hesitate to contact your insurer. An agent will be able to explain your coverage and answer any questions you may have.
Keep Yourself Safe on Your Travels
Typically, the answers to questions like “Can I use my health insurance in another state?” and “Will my health insurance work in another state?” are both “it depends.” It’s best to review your insurance plan details to see what kind of care or providers are considered to be in-network. When in doubt, it’s best to contact your insurance carrier directly to verify.
Nevertheless, if you want a bit of extra security, you may want to consider supplemental coverage, a type of health insurance that can cover some of the unexpected costs of out-of-state (or even out-of-country) medical care. Two of these supplements are accident insurance and critical illness insurance.
These plans have specific stipulations as to what they may cover. Before choosing between standard health insurance or a supplemental plan, make sure you fully understand what the two cover and what they do not. It may take some time, but it will be well worth the peace of mind.