Does Insurance Cover Emergency Room Visits? Avoid Surprise Costs

Each year, 139.8 million emergency room visits occur in the US. Most insurance policies provide financial protection for emergencies; however, patients are often responsible for out-of-pocket costs, including copayments and coinsurance. Insurance coverage often depends on whether the hospital or provider is in-network, leading to unexpected bills.

Reforms like the No Surprises Act and changes under the Affordable Care Act aim to reduce these financial burdens.

Continue reading to learn how insurance covers emergency room visits and what you need to know to avoid costly surprises.

Insurance Coverage Emergency Room Visits

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Health insurance generally covers emergency room visits, depending on the plan. Most insurance policies offer protection for medical emergencies, but patients may still face out-of-pocket costs like copayments and coinsurance.

The coverage can also vary based on whether the emergency room and providers are in-network or out-of-network.

In-Network vs. Out-of-Network Providers

In-network emergency room visits are generally covered more fully by insurance plans. When patients go to an in-network emergency room, they usually pay lower out-of-pocket costs, including reduced copayments and coinsurance.

However, copay and coinsurance costs can increase if an out-of-network provider treats a patient. The No Surprises Act was implemented to address this issue by protecting patients from large out-of-network bills during emergency room visits.

Under this law, patients are only responsible for paying the same out-of-pocket amount they would for an in-network provider, regardless of the hospital or doctor's network status.

Affordable Care Act on Emergency Room Coverage

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The Affordable Care Act (ACA) has influenced emergency room coverage by expanding insurance access and promoting integrated care.

Although the ACA does not focus on creating specific payment models for emergency departments, it has increased demand for emergency services, especially in states that expanded Medicaid.

For instance, Medicaid beneficiaries in Oregon experienced a 40% increase in emergency department usage after the state’s Medicaid expansion.

Furthermore, ACA's expansion of health coverage, including through Medicaid, has resulted in more emergency department visits. For instance, between 2011 and 2019, California saw a 39.1% increase in emergency visits among Medicaid patients.

Medicare and Emergency Room Coverage

Medicare Part B typically covers emergency room visits for injuries, sudden illnesses, or worsening conditions.

After meeting the Part B deductible, patients are responsible for a copayment for each emergency room visit and 20% of the Medicare-approved amount for doctor services.

Medicare Beneficiaries

For Medicare beneficiaries, the out-of-pocket cost of an emergency room visit includes a copayment and coinsurance for doctor services.

Medicare covers 80% of the Medicare-approved amount, while the patient covers the remaining 20% after meeting the deductible.

Suppose a patient is admitted to the same hospital within three days of the emergency room visit. In that case, the visit is considered part of their inpatient stay, and the copayment for the emergency room visit does not apply.

Medicare Advantage and Emergency Room Visits

Medicare Advantage plans cover everything Original Medicare does, including emergency room visits. Patients pay copayments or coinsurance, which vary by plan, but the coverage is guaranteed for both in-network and out-of-network emergency visits.

Emergency Room Coverage by Private Insurers

Private insurance generally covers emergency room visits, but the costs depend on the plan details. Most plans cover emergency care, but the out-of-pocket expenses, such as copayments and coinsurance, can vary.

1. Aetna

Aetna covers emergency care 24/7, regardless of where the emergency occurs. Patients are responsible for any copayments outlined in their plan. For immediate medical attention, an in-network provider visit requires a $150 copay per visit, with the deductible not applying.

For out-of-network providers, the copay remains $150 per visit, and the deductible also does not apply. However, an emergency room copay does not apply when admitted for an overnight hospital stay.

2. UnitedHealthcare

UnitedHealthcare covers emergency care, requiring patients to pay 30% coinsurance after meeting their deductible. If the patient is not admitted to the hospital, an additional $500 fee is charged for each emergency room visit.

3. Pivot Health

Pivot Health plans include emergency room coverage with varying deductible options. After meeting the deductible, patients pay 20% coinsurance until reaching their out-of-pocket maximum. The plan also includes an emergency room copay if the patient is not admitted.

4. Cigna

Cigna provides emergency and urgent care coverage at all times and locations. Patients should seek immediate medical care by going to the nearest facility or calling 911 in emergencies. Cigna covers emergency services 24/7, even away from home.

A network provider visit requires a $250 copay per visit, with the deductible not being applied. For out-of-network providers, the copay remains $250 per visit without the deductible. The $250 copay is waived if the patient is admitted to the hospital as an inpatient within 24 hours.

Average Costs for Private Insurance Holders

For individuals with large employer-sponsored health plans, the average out-of-pocket cost for an emergency room visit is $646. Some visits cost as little as $128, while others exceed $907. This variation depends on the services provided during the visit, such as imaging or lab tests, which often incur higher facility fees.

Facility and Professional Fees

Emergency room bills are generally divided into facility and professional fees. Facility fees, which cover the use of hospital resources, make up about 80% of the total cost of an emergency room visit. The remaining 20% typically comes from professional fees, such as physician services and other medical staff charges.

Regional Differences in Emergency Room Costs

Emergency room costs vary widely by geographic location. In cities like San Diego, the average cost for an emergency room visit is as high as $3,761, while in Baltimore, the average is just $1,645. Factors contributing to these differences include the type of facility and the complexity of the services.

Ambulance Services

Coverage for ambulance services can vary. While the No Surprises Act protects patients from surprise medical bills for air ambulance services, this law does not cover ground ambulance services. This means patients might still receive out-of-network bills for ground ambulance services, depending on their insurance and state laws.

Wrap Up

Insurance generally covers emergency room visits, though costs vary based on plan details and provider networks. Patients are often responsible for out-of-pocket expenses such as copayments and coinsurance, with average costs for an emergency room visit around $646. However, they can exceed $3,700 depending on services and location.

Reforms like the No Surprises Act reduce unexpected billing. Yet, factors such as in-network versus out-of-network care, regional price differences, and separate ambulance fees can still result in substantial charges. Understanding your insurance coverage is vital to managing and minimizing these expenses during emergency care.

FAQs on Insurance in Emergency Room

Do short-term health insurance plans cover emergency room visits?

Yes, many short-term health insurance plans cover emergency care and hospitalization. Some plans may not include prescriptions or routine preventive care.

If I’m having problems with my insurance, where can I file a complaint?

Call the member services number on your health plan card. You can resolve the issue over the phone or file a formal complaint directly with your health plan.

Does health insurance cover follow-up care after an emergency room visit?

Yes, follow-up care is generally covered, and protections against unexpected out-of-network bills for post-stabilization services are in place. However, signing a consent form from an out-of-network provider may waive those protections.

Are emergency rooms required to treat me?

Yes. Under the 1986 EMTALA law, Emergency Rooms must assess and treat life-threatening emergencies. If they can’t treat you, they must transfer you to a facility that can. In May 2024, CMS added an option on CMS.gov for filing complaints if EMTALA isn’t followed.