Yes, you can use your health insurance in a different state, given the procedure is for a qualified emergency. However, every insurance company has its own rules surrounding non-emergency out-of-state health coverage. Most companies will not fully cover routine preventative healthcare outside your policy’s approved provider network. Even if your company allows out-of-network care, you will likely have to pay more for the service.
Table of Contents
Staying Covered No Matter Where You Are
While traveling, you may find yourself in a situation where you need to see a doctor, receive emergency care, or fill a vital prescription. Out-of-state health insurance coverage depends on a few key policy details:
- The size and reach of your insurance company’s approved network providers
- What your carrier considers an emergency, and how they cover one
- Your insurance carrier’s stance on receiving prior approval for out-of-state services
Contact your insurance carrier before leaving town to ensure you understand their approach to out-of-state benefits and guarantee yourself thorough protection while traveling. In this article, we’ll cover the different types of provider networks, how they work from state to state, the criteria for an approved service, and common out-of-state insurance situations.
How Does Health Insurance Work in Different States?
For a monthly premium payment, health insurance helps cover costly medical bills that many people cannot afford out-of-pocket. Your insurance provider’s stance on out-of-state cost-sharing will depend on your plan type:
- Network-Based Plan: This is the most common type of health coverage and suits most people with relatively routine and localized lives. Network-based plans have contracts with preferred medical facilities and providers. Receiving care outside your preferred network can result in higher out-of-pocket costs or declined coverage.
- Nationwide Plan: Nationwide networks have eligible doctors and hospitals in every state. While these plans still require members to stay within a preferred medical network, their broad reach better suits individuals who live and work in multiple states.
Understanding Your Provider Network
Before using your insurance benefits across state lines, you must understand how your healthcare network functions. Standard networks include:
Plan Type | How This Plan Works | Are You Covered Out-of-Network? |
|---|---|---|
PPO | PPOs cost more than other plans but allow flexibility to see doctors outside your healthcare network, typically without requiring a referral. | Yes, but for higher out-of-pocket costs. |
HMO | Though HMOs cost less than PPOs, they require you to see the same primary care provider (PCP). Your PCP must refer you for services from other in-network specialists. | No, except for emergencies. |
POS | POS plans resemble PPOs but cost less and offer less flexibility. Like HMOs, you may need referrals from your PCP to see outside specialists. | Yes, but it will cost more. |
EPO | In terms of cost and flexibility, EPOs also fall somewhere between HMOs and PPOs. EPOs limit your network of doctors but do not require PCP referrals. | No, except for emergencies. |
Catastrophic | Available for individuals under 30, catastrophic health insurance covers emergencies for low monthly premiums and high deductibles. | Yes, given this coverage only applies to emergencies. |
HDHP | These plans exchange lower monthly premiums for high deductibles and typically get paired with tax-advantaged health savings accounts (HSAs). | Yes, you can use funds in your HSA for any eligible medical expense. |
Emergency Care
All health insurance plans must cover emergency services provided at any hospital in any state outside of Hawaii. However, the definition of an emergency will vary from company to company. Furthermore, while some companies will allow you to receive emergency services at urgent care facilities, others will require you to go to the hospital. Ensure you understand your provider’s stance on emergency care to avoid unexpected charges.
Telehealth
Since the COVID-19 pandemic, more people have begun using telehealth to consult with specialists over state lines. Generally speaking, you can still see a provider back home over telehealth while temporarily traveling out of state. However, telehealth restrictions vary state-to-state and are changing rapidly with the times. Some states currently allow out-of-state physicians to practice online, given they follow that state’s requirements, while others will only license out-of-state doctors for 30-day intervals.
Should You Change Your Health Insurance?
If you need a health insurance policy with more flexible travel benefits, you can shop for a new plan on the ACA marketplace. Most people will need to change plans if they intend to move to a new state, have a job or lifestyle requiring frequent traveling, or will soon begin attending college across state lines.
Moving to a New State
If you need to change your health insurance because you plan on moving to a new state, update your personal information and address to assess your updated marketplace policy options. You will come against various eligibility requirements and premium rates on a state-to-state basis, so prepare yourself accordingly.
Though you can typically only enroll in ACA insurance during its open enrollment period of November 1-January 15 each year, a permanent move would make you eligible for a special enrollment period (SEP). SEPs typically grant candidates an additional two months to apply. To qualify for a SEP, you must prove you had previous health coverage at least one day during the 60-day window before moving.
Traveling
If vacationing temporarily, you likely will not require routine medical services such as doctor’s checkups and diagnostic screenings. However, some travelers find themselves in emergency situations requiring urgent medical care. Contact your insurance provider to find out more about how they define an emergency, how they would cover one, and how to file a claim.
If your policy imposes stringent emergency criteria, you may want to consider an additional travel insurance policy. However, since all insurers must cover emergencies in all American states, travel insurance is often not necessary unless you plan on traveling abroad.
Attending College in a Different State
While health insurers must legally cover children under their parent’s policies until they turn 26, network coverage gets complicated for dependents attending out-of-state colleges. Even if their policies allow it, out-of-state beneficiaries will still have to pay higher out-of-pocket costs to see out-of-network providers. Most transfer students ultimately prove better off securing standalone coverage.
As with any move, attending college out of state will qualify you for a special enrollment period. You can verify your SEP eligibility by calling your new state’s insurance department. You may also qualify for an ACA student plan, which provides basic and affordable coverage for eligible college enrollees.
Alternatives to Traditional Health Insurance
If conventional health insurance would not sufficiently cover your out-of-state adventures, you can explore alternative options such as Medicare, Medicaid, or a health savings plan. While these policies serve the same function as ACA marketplace plans, they impose their own rules and regulations.
How Medicare Works in Different States
Medicare is federally subsidized health insurance for seniors over 65 and people with qualifying disabilities. If you have Original Medicare, you can receive eligible medical care in all 50 states, Washington DC, and every American territory (Guam, Puerto Rico, etc). Almost all doctors and hospitals accept Medicare.
Original Medicare must provide Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) for all eligible members. Beneficiaries can also purchase separate prescription drug coverage through Medicare Part D. If Original Medicare does not suit your needs, you can opt into Medicare Advantage (Part C), which outsources Medicare coverage through private companies that impose their own coverage limits and price structures.
How Medicaid Works in Different States
Medicaid is a nationwide program providing medical insurance to low-income individuals, families, and specific disabled populations. Each state manages its own Medicaid eligibility and benefits within federal guidelines, meaning you can only receive Medicaid-covered care within the state that insures you. To ensure coverage during a move, you must cancel Medicaid in your old state and reapply through your new state after you relocate.
As with ACA health insurance, Medicaid must still cover eligible out-of-state emergencies. However, if you formally request coverage in advance, Medicaid may authorize special situations on a case-by-case basis. If you live near a state boundary, you may qualify for Medicaid coverage in your neighboring state if receiving primary care in your home state proves a notably further commute.
How Your Health Savings Plan Works in Different States
Health savings accounts allow members to set aside pretax funds, accessible later for use on qualified medical expenses through an HSA debit card. You can use these cards for eligible services or medications in-store or online, even when traveling out of state or abroad. Only people with HDHP plans qualify for a supplemental HSA.
All in All
While moving, traveling, or attending college across state lines can provide an exciting new chapter in life, it often brings about some logistical complications. Since every state and insurance company imposes its own rules surrounding out-of-state coverage, ensure you have dependable healthcare before setting off on your next adventure. Most importantly, understand how your provider covers emergency medical services, regardless of location. If you break your leg or develop a life-threatening illness far from home, the last thing you want to return to is an unexpected medical bill.