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HEALTH Insurance
HEALTH INSURANCE INSIGHTS

The Affordable Care Act requires health insurance to cover emergency care. Although emergency room visits are covered by insurance, you may be responsible for a deductible or copayment.

Your health insurance plan covers emergency care, but you’ll likely have to pay a copayment and may have to pay your deductible as well.

The Affordable Care Act requires health insurance to cover 10 essential health benefits. One of those benefits is emergency care. Whether you have employer-sponsored health insurance, an individual health plan, Medicare or Medicaid, the plan will provide emergency room coverage.

Whether the emergency room is in or out of network, you’ll pay the same copay and coinsurance. That said, you may pay more at the out-of-network hospital if you’re admitted. Read on to learn how insurance covers the emergency room.

KEY TAKEAWAYS
  • Health insurance covers emergency room visits, but there are usually copays or coinsurance amounts, and you may have to pay your deductible.
  • Your health insurance company has to pay for emergency care even if the hospital is out-of-network.
  • If you receive an unexpected bill from an emergency room visit, you can appeal it with your insurance company.

Are emergency room visits covered by health insurance?

Your health insurance will cover you for a trip to the emergency room, whether that hospital is in or out of network.

However, emergency room visits are subject to copays, coinsurance, and deductibles depending on your policy. Although network doesn’t matter for emergency care, if you are admitted to an out-of-network hospital you may have to pay higher coinsurance amounts.

Can you buy emergency health insurance?

There’s really no such thing as emergency-only health insurance. It’s a common misconception that catastrophic health insurance plans are emergency health insurance, but they actually cover all of the same things as any other plan. They just have higher out-of-pocket costs.

Also, regardless of whether you have health insurance, emergency departments must treat you if it’s an emergency. You may wind up with a hefty hospital bill if you visit an emergency room without insurance, but they must care for you in an emergency.

Why insurance might not pay for an emergency room visit

Health insurance has to cover your emergency room care, but there are two occasions when you may receive a larger than expected hospital bill:

  • An out-of-network provider cares for you during a hospital visit or stay.
  • Your insurer deems your issue wasn’t an emergency and you should have sought care at a more appropriate care location, such as a doctor’s office or retail clinic.

Health insurance companies have contracts with hospitals and providers. Health plans generally approve emergency room claims, but a doctor or technician might not be within your health plan’s network. In that case, you might get a larger than expected bill if one of the professionals who cared for you is considered out-of-network.

The other occasion when you might receive a larger bill is if you go to the emergency room for non-emergency care. Some insurers nudge members to get lower-cost care rather than go to an emergency room unless it’s an actual emergency. This will save you money on coinsurance as well.

Those lower-cost care locations include a primary care provider’s office, an urgent care center or a health clinic. Insurers want members to get care at those locations for non-emergencies. Doing so not only reduces health costs for health plans but minimizes the chance of overcrowded emergency rooms.

Health insurers may reject a claim for an emergency room visit that it deems unnecessary. This is a practice that’s still not common but is something to watch for when you receive the bill after an emergency room visit.

What to do if you get a surprise emergency room bill

Out of every 5 emergency room visits, one results in a surprise medical bill, according to a Peterson-KFF study.It could be that the hospital made a claims error, an out-of-network provider assisted in your care or the bill is simply larger than you expected.

Check your hospital bill for any unexpected charges. If you find you’re getting charged out-of-network for part of the care, you can appeal it to your insurer. You’ll want to explain the situation and provide information about the visit. Usually, health plans allow two internal appeals and one external appeal of a surprise medical bill.

Your first call should be to the hospital. You can ask the hospital if it will accept a reduced payment, such as the Medicare rate, which is lower than what private insurers usually pay. Hospitals also often offer financial assistance and payment plans.

Also, check with your insurer. Request that it negotiate a lower rate with the hospital for your charges. You can also appeal the surprise bill with the insurer.

If you’re still not getting any help, contact your state’s insurance department. The state may work with the hospital and insurer to lower the price or review an insurer’s rejected appeal.

You can also check out the National Patient Advocate Foundation, which offers help on its site on appealing surprise medical bills, including template appeal letters.