Having health insurance does not necessarily mean an emergency room visit will be free.
In the United States, the amount you may ultimately pay for emergency care depends on several factors, including:
- your health insurance plan,
- your deductible,
- copayments,
- coinsurance,
- which services you receive,
- whether those services are covered,
- and federal or state billing protections that apply to the situation.
The good news is that federal law now provides important protections against many unexpected out-of-network emergency medical bills.
Understanding how these rules work can make an emergency room bill much less confusing.
How Does Health Insurance Pay for an Emergency Room Visit?
When you receive covered emergency care, the hospital and other healthcare providers generally submit claims to your health insurance plan.
Your insurer processes those claims according to the terms of your coverage.
The amount charged by the hospital is therefore not necessarily the same amount:
- your insurer allows,
- your insurer pays,
- or you ultimately owe.
After the claim is processed, your insurer will usually provide an Explanation of Benefits (EOB) showing how the claim was handled.
An EOB is not itself a medical bill.
Why Might You Still Owe Money When You Have Insurance?
Health insurance usually involves some form of cost-sharing.
This means the insurance company pays according to the plan's rules while you may remain responsible for part of the cost.
Three terms are particularly important.
1. Deductible
A deductible is generally the amount you pay for covered healthcare services before your insurance plan begins paying according to the plan's terms.
For example, if your plan has an annual deductible and you have not yet met it, you could be responsible for a substantial portion of the allowed cost of your emergency care.
The exact rules depend on your plan.
Some services may have different deductible arrangements.
2. Copayment
A copayment, commonly called a copay, is a fixed amount you pay for a covered healthcare service.
For example, a health plan might require a particular copayment for an emergency department visit.
The actual amount depends on your plan.
Some insurance plans may have different copayment arrangements depending on the type of healthcare received.
3. Coinsurance
Coinsurance is a percentage of the cost of a covered healthcare service that you are responsible for paying, generally after applicable deductible requirements have been met.
For example, if your plan requires 20% coinsurance for a particular covered service, you may be responsible for 20% of the plan's allowed amount while the insurer pays according to the policy.
Again, the actual percentage and rules depend on your insurance plan.
Why the Hospital's Original Charge May Not Be What You Pay
Medical billing involves several different numbers.
You may encounter:
Provider charge: The amount the healthcare provider initially bills.
Allowed amount: The amount recognized under the insurance arrangement for the covered service.
Amount paid by insurer: What the health plan pays.
Patient responsibility: What the insurer indicates you may owe after it processes the claim.
These figures can differ substantially.
This is one reason you should review your Explanation of Benefits before assuming the hospital's original charge represents your final financial responsibility.
What Is an Explanation of Benefits?
An Explanation of Benefits (EOB) is a statement from your health insurance company explaining how a healthcare claim was processed.
It commonly includes information such as:
- the healthcare provider,
- date of service,
- services submitted,
- provider charges,
- allowed charges,
- amount paid by the insurer,
- and the amount shown as your responsibility.
CMS specifically explains that an EOB is not a bill.
When the actual medical bill arrives, compare it with your EOB.
If the provider's bill is higher than the patient balance shown on your EOB, contact the provider and insurer to investigate the discrepancy.
What Does In-Network Mean?
An in-network provider has an agreement with your health insurance plan to provide covered healthcare services under negotiated arrangements.
For planned healthcare, using an in-network provider generally costs less than using an out-of-network provider.
What Does Out-of-Network Mean?
An out-of-network provider does not have a contract with your health insurance plan.
For ordinary non-emergency healthcare, receiving care outside your network can sometimes result in substantially higher costs or reduced insurance coverage.
Emergency care, however, has special federal protections in many circumstances.
What Is the No Surprises Act?
The No Surprises Act is a U.S. federal law that took effect on January 1, 2022.
Among its provisions are protections against many unexpected out-of-network medical bills.
For people using most types of private health insurance, the law generally provides protections involving:
- emergency room services,
- certain non-emergency services involving out-of-network providers at in-network facilities,
- and air ambulance services.
This is a major change from the healthcare-billing environment that existed when the original version of this article was published in 2016.
What Happens If the Emergency Room Is Out of Network?
Under federal protections, when covered emergency services fall within the No Surprises Act, patients generally cannot be required to pay more than the applicable in-network cost-sharing amount simply because the emergency provider or facility was out of network.
In other words, covered patients are protected from many forms of surprise balance billing for emergency services.
However, this does not necessarily mean the emergency visit is free.
You may still owe legitimate:
- deductibles,
- copayments,
- or coinsurance
according to your health plan and applicable law.
Do You Need Prior Authorization for Emergency Care?
In a genuine emergency, you should not delay appropriate treatment while trying to obtain insurance authorization.
HealthCare.gov states that insurers cannot require prior approval before you obtain emergency room services from an out-of-network provider or hospital in a true emergency.
If you believe you are experiencing a serious medical emergency, seek appropriate emergency care.
Insurance questions can be addressed afterward.
Does the No Surprises Act Cover Every Health Plan?
No.
The federal protections apply broadly, but not every healthcare arrangement is governed in exactly the same way.
CMS explains that the protections apply to most types of private health insurance.
People covered through programs such as:
- Medicare,
- Medicaid,
- Indian Health Service,
- Veterans Affairs healthcare,
- and TRICARE
already have other protections against certain unexpected out-of-network bills.
Other forms of coverage can also have different rules.
Always determine which protections apply to your particular health plan.
What About Ground Ambulance Bills?
This is an important exception.
Federal No Surprises Act protections generally do not currently cover ground ambulance services, although state laws may provide additional protections in some circumstances.
That means an out-of-network ground ambulance can potentially produce different billing issues.
Air ambulance services have different federal protections under the No Surprises Act.
If you receive an unexpected ambulance bill, investigate the specific protections that apply in your state and under your insurance plan.
Can an Emergency Room Visit Produce More Than One Bill?
Yes.
This surprises many patients.
A single emergency visit can sometimes involve separate charges from different healthcare entities or professionals.
Depending on what happened during your visit, bills or claims could involve:
- the hospital,
- emergency physicians,
- radiology,
- laboratory services,
- specialists,
- ambulance services,
- or other healthcare providers.
Do not assume every document you receive is a duplicate.
Compare each bill with your EOBs and the services you received.
Why Can Emergency Room Care Be Expensive Even With Insurance?
Emergency departments maintain resources necessary to provide care at all hours for conditions ranging from relatively minor injuries to life-threatening emergencies.
But from the patient's perspective, the final amount owed depends heavily on the insurance plan.
Two insured people receiving similar emergency treatment could potentially have different out-of-pocket costs because their:
- deductibles differ,
- copayments differ,
- coinsurance rates differ,
- plan benefits differ,
- or they have already paid different amounts toward their annual deductible or out-of-pocket limit.
Therefore, there is no single price that accurately represents what every insured patient will pay for an emergency room visit.
What Is an Out-of-Pocket Maximum?
Many health plans have an annual out-of-pocket maximum.
This generally limits how much you must pay during the plan year for your share of certain covered healthcare costs.
Qualifying spending can include applicable:
- deductibles,
- copayments,
- and coinsurance.
Once the applicable out-of-pocket maximum is reached, the plan generally pays the covered costs specified under its terms for the remainder of that coverage period.
However, not every healthcare expense necessarily counts toward the limit.
For example, premiums and certain non-covered expenses generally do not count.
Check your plan documents for the exact rules.
How Can You Estimate Your Emergency Room Costs?
You cannot always predict emergency healthcare costs in advance, particularly because clinicians may not know which tests or treatments are required until you have been assessed.
But you can understand your insurance benefits before an emergency occurs.
Check your Summary of Benefits and Coverage (SBC) or other plan documents.
Look specifically for information about:
- emergency room copayments,
- emergency services coinsurance,
- deductibles,
- out-of-pocket maximums,
- ambulance coverage,
- and other emergency-care rules.
CMS explains that health plans provide a Summary of Benefits and Coverage to help consumers understand and compare health insurance benefits.
Questions to Ask Your Insurance Company Before You Need Emergency Care
When reviewing your insurance, useful questions include:
What is my emergency room copayment?
Does my deductible apply to emergency services?
What coinsurance applies after the deductible?
What is my annual out-of-pocket maximum?
How much have I already paid toward my deductible and out-of-pocket maximum?
How does my plan cover ground and air ambulance services?
What happens if emergency care is provided out of network?
How do I appeal a claim if I believe it was processed incorrectly?
Understanding these details before an emergency occurs can make the billing process easier afterward.
What Should You Do After an Insured Emergency Room Visit?
Once the immediate medical issue has been dealt with, organize the financial paperwork.
Review your EOB
Check:
- services,
- dates,
- provider charges,
- allowed amounts,
- insurer payments,
- and patient responsibility.
Compare the EOB With Your Medical Bills
The amounts should make sense together.
If something appears inconsistent, investigate it.
Request an Itemized Bill if Necessary
An itemized bill can show the individual services and charges involved.
Check for Duplicate or Unfamiliar Charges
If you don't recognize something, ask the billing department to explain it.
An unfamiliar charge is not automatically an error.
Contact Your Insurer
If you believe your insurance should have paid more, ask how the claim was processed and whether you have appeal rights.
What If Insurance Denies the Emergency Claim?
Do not automatically assume a denial is correct.
First determine why the claim was denied.
Possible issues can include:
- incorrect information,
- coding problems,
- questions about coverage,
- administrative errors,
- or other plan-specific reasons.
Read the EOB carefully and contact your insurer.
If you disagree with the decision, ask about the formal appeals process and relevant deadlines.
Keep copies of correspondence and records of telephone conversations.
What If You Receive a Surprise Out-of-Network Bill?
If you have most types of private insurance and receive an unexpected out-of-network emergency bill, check whether the No Surprises Act applies.
CMS provides a specific action plan for unexpected emergency room bills.
If you believe a provider, facility or insurer is not following federal billing protections, you may be able to file a complaint through the appropriate federal process.
State consumer-assistance programs may also provide help.
Don't Ignore a Bill Because You Think Insurance Should Pay It
Insurance disputes and provider bills do not always resolve automatically.
If a bill appears incorrect:
- contact the provider,
- contact the insurer,
- document the dispute,
- and follow applicable appeal or complaint procedures.
Ignoring correspondence can make resolving the situation more difficult.
What If You Cannot Afford Your Share of the Bill?
Even after insurance has paid, deductibles, copayments and coinsurance can leave some patients with substantial bills.
If you cannot afford your patient responsibility, ask the hospital whether it offers:
- financial assistance,
- charity care,
- hardship discounts,
- payment plans,
- or other assistance.
Having health insurance does not necessarily prevent you from qualifying for some forms of hospital financial assistance.
Eligibility depends on the hospital's policies and your circumstances.
Should You Use a Credit Card to Pay Immediately?
Don't assume you need to transfer the entire medical bill to a high-interest credit card immediately.
First:
- make sure insurance processed the claim correctly,
- compare the bill with the EOB,
- investigate surprise-billing protections,
- check for billing errors,
- ask about financial assistance,
- and investigate hospital payment arrangements.
Once medical expenses are converted into ordinary credit-card debt, different financial terms apply.
Don't Delay Emergency Care to Compare Insurance Networks
For planned healthcare, checking whether a provider is in network can save money.
A genuine emergency is different.
If someone has symptoms suggesting a serious or life-threatening condition, don't spend critical time searching for an in-network hospital solely to reduce costs.
HealthCare.gov advises people experiencing a true emergency to obtain care from the closest hospital capable of helping them.
Emergency Care Should Be Based on Medical Need
Examples of potentially serious symptoms include:
- severe difficulty breathing,
- severe chest pain,
- signs of stroke,
- uncontrolled bleeding,
- loss of consciousness,
- severe allergic reaction,
- major trauma,
- or other potentially life-threatening symptoms.
Seek appropriate emergency care when needed.
Financial and insurance questions can be dealt with after immediate medical needs have been addressed.
A Note for Readers Outside the United States
This article specifically explains U.S. health insurance and emergency-room billing.
Terms such as:
- deductible,
- copayment,
- coinsurance,
- provider network,
- Explanation of Benefits,
- and the No Surprises Act
are discussed within the context of the American healthcare system.
Healthcare financing differs significantly between countries.
If you live elsewhere, check the rules provided by your national health service, insurer, government health authority or healthcare provider.
The Bottom Line
Having health insurance can substantially change how emergency-room costs are handled, but insurance does not necessarily mean you will pay nothing.
Your final responsibility may depend on your:
- deductible,
- copayment,
- coinsurance,
- covered services,
- out-of-pocket maximum,
- and other terms of your insurance plan.
Federal law now provides important protections against many unexpected out-of-network emergency bills for people with most types of private health insurance.
After an emergency visit, review your Explanation of Benefits, compare it with your provider bills and investigate anything that does not appear correct.
If you cannot afford the remaining amount, ask the hospital about financial assistance before assuming expensive borrowing is your only option.
Most importantly, don't delay necessary emergency treatment because you are worried that the closest appropriate hospital may be outside your insurance network.
Disclaimer
This article provides general educational information about U.S. health insurance and emergency-room billing. It is not medical, legal, financial or insurance advice. Insurance benefits, state laws, federal regulations and hospital policies can change and vary according to individual circumstances. Check your current health-plan documents and consult your insurer, healthcare provider or appropriate government agency for information specific to your situation.
Sources and Further Reading
Centers for Medicare & Medicaid Services — Know Your Rights With Insurance
https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/know-your-medical-bill-rights/know-your-rights-insurance
Centers for Medicare & Medicaid Services — Medical Bill Rights
https://www.cms.gov/medical-bill-rights
Centers for Medicare & Medicaid Services — How to Read a Health Insurance Explanation of Benefits
https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/medical-bill-guides-resources/how-read-health-insurance-explanation-benefits
Centers for Medicare & Medicaid Services — Health Insurance Terms You Should Know
https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/medical-bill-guides-resources/health-insurance-terms-you-should-know
Centers for Medicare & Medicaid Services — Surprise Bill for Emergency Room Visit Action Plan
https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/find-action-plan-your-medical-bill/action-plan-surprise-bill-emergency-room-visit
HealthCare.gov — Getting Emergency Care
https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/
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