Does Medicaid Cover Emergency Room Visits?
- Get the facts about when Medicaid covers emergency room visits. Find out what you have to pay out of pocket when you visit the ER and have Medicaid coverage.
When a medical emergency arises, you want to seek care as fast as possible, but worries about how you'll pay for the cost of a trip to the ER may have you thinking twice about getting the help you need. Understanding how and when Medicaid covers emergency room visits can help you make an informed decision when you're in need of prompt medical care.
Does Medicaid Cover Emergency Room Visits?
Medicaid is a partnership between federal and state agencies. The federal government establishes some nationwide regulations for Medicaid and provides funding for the program. Then, the states are free to create a system of rules and requirements for their own Medicaid programs. Laws require that all states' Medicaid programs cover outpatient hospital services, including emergency room visits. Some states may exclude certain services performed in an ER from coverage and require you to pay for them out of pocket.
Is There a Copay on Medicaid?
Some states have established copay policies to help reduce some of their expenses associated with paying for care. If you live in a state that has copays for ER visits, the amount of your copay is determined by your state's Medicaid rules.
Flat Fee Copays
In some states, copays are a flat fee that everyone pays for a certain type of care. For example, the Kaiser Family Foundation reports that the copay for an ER visit was $3 in Mississippi and $4 in Oklahoma.
Set Percentage Copays
Some states like Alaska and South Dakota require you to pay for a certain percentage of what the emergency room bills Medicaid.
States like New York and Montana determine copays based on how your income compares to the Federal Poverty Level (FPL). The Department of Health and Human Services establishes new guidelines based on household size every year. For 2021, the annual income guidelines for the 48 contiguous states and the District of Columbia include:
- $12,880 for single people
- $17,420 for two family members, such as a married couple with no children or a single parent with one child
- $21,960 for three family members
- $26,500 for four family members
- $31,040 for five family members
- $35,580 for six family members
- $40,120 for seven family members
- $44,660 for eight family members
Due to variations in costs of living, Alaska and Hawaii have higher limits for federal poverty guidelines.
In states where the FPL is used to determine copays, your rate of pay is determined by your modified adjusted gross income (MAGI). This figure includes the amount of taxable income that you make during one tax year and untaxed foreign income, non-taxable Social Security benefits and tax-exempt interest earned in accounts in your name.
To determine the amount of your copay, divide your MAGI by the FPL level that applies to you and multiply by 100. For example, if you're a single person with an MAGI of $13,000, the calculation would be:
13,000 ÷ 12,880 x 100 = 100.93% FPL
Generally, people with a lower percentage FPL pay a smaller copay than those with higher FPL percentages.
In some states like Pennsylvania and North Carolina, cpays are determined by the services provided while you're in the ER. You'll pay a higher co-pay for some services.
When Do You Pay a Copay for Emergency Room Visits?
In states that require copays for emergency room visits, established guidelines detail when copays may be assessed. Some states opt to charge copays for all emergency room services. In others, you may only have to pay a copay if your visit is not for a true medical emergency. For example, if you have a sinus infection and go to the emergency room, you may be required to pay a copay because a family doctor could have provided the care you needed.
States may also mandate that you receive prior approval before visiting the emergency room for any service. The physician treating you in the ER may need to seek authorization for payment before providing certain treatments or services.
When Should I Choose Urgent Care Instead of the ER?
Urgent care centers treat injuries and illnesses that aren't life threatening but require prompt attention, such as:
- Eye irritation
- Flu symptoms
- Mild to moderate breathing problems
- Minor broken bones
- Minor cuts and scrapes that require stitches
- Persistent cough
- Skin rashes
- Sore throat
- Stomach problems like vomiting and diarrhea
- Urinary tract infections
Medical emergencies that should be treated in the ER include:
- Complex fractures
- Heart attack
- Inability to breathe
- Knife and gunshot wounds
- Loss of consciousness
- Moderate to severe burns
- Problems related to pregnancy
- Serious injury to the back, head or neck
- Severe pain, particularly in the chest or abdomen
- Suicidal thoughts or attempts at self-injury
- Uncontrollable bleeding
Does Medicaid Cover Urgent Care?
States can determine whether to cover urgent care under their Medicaid programs. If your state's program covers urgent care, you may have to choose an urgent care center in your network. Even if you're not required to choose someone in network, some centers may not accept those with Medicaid coverage. You may be assessed a copay for urgent care services, and your state may not cover some types of services performed in an urgent care clinic.