Health Insurance

Does Health Insurance Always Cover Emergency Room Visits?

Talor Bianchini
Talor Bianchini12 Dec 2022

Emergency room (ER) visits can get very expensive, very quickly. For those who have health insurance, an ER visit will be covered by your insurance in most cases. In some instances, like for the treatment of minor illnesses, you may be responsible for the out-of-pocket costs. Some emergencies can be treated at urgent care facilities instead of ERs to save money, such as sprains and stitches.

With a Mira membership, you can get access to low-cost urgent care visits to save you even more money. In addition, members get low-cost virtual care, up to 80 percent off over 1000 different prescription medications, and same-day lab testing, for an average of $25 a month. Why spend when you could save? Sign up for Mira today. 

Does Health Insurance Always Cover Emergency Room Visits?

In general, health insurance companies will cover the cost of a visit to the emergency room (ER). The Affordable Care Act (ACA) requires companies to cover emergency services, as it is considered an essential health benefit. Your visit to the ER must be deemed an emergency, which is defined as a sudden life-threatening injury or illness that requires immediate medical attention. This may include situations like:

  • Stroke
  • Heart attack
  • Severe burns
  • Seizure
  • Severe bleeding
  • Unconsciousness

You are able to visit an emergency room in any situation that you see fit. Depending on the type of insurance plan you have, you may need to pay a deductible before the company begins covering the cost. 

However, you should note that treatment for minor illnesses, may not be considered an emergency service, and may result in you covering the out-of-pocket expenses. In addition, visiting the ER when you don’t necessarily need to may be a waste of your time. People who have more severe conditions are likely to be seen quicker. 

These policies apply to most major medical insurance companies, including Medicare and Medicaid. Another aspect of ACA (or Obamacare) is that insurance cannot charge you more for seeing an out-of-network provider or visiting an out-of-network facility. They are required to charge you the same coinsurance or copayment regardless of where you go. In addition, your insurance provider cannot force you to get pre-authorization before visiting the ER. 

Understanding Your ER Bill

If you have visited the ER, you will receive a bill that itemizes all the charges you incurred during your visit. Reading and understanding this bill can be very confusing, especially if you haven’t been to the ER before. One study estimated that 72 percent of Americans are confused by their medical bills. This is typically attributed to hard-to-decipher medical jargon and unfamiliar procedural codes. 

Your bill will include any procedures or lab tests, any medicines you were given, and supplies used during your visit. A separate bill may also arrive outlining the fees for seeing a healthcare provider. Those with insurance will also receive an Explanation of Benefits (EOB) form from their insurance company. This will explain:

  • Copayments/coinsurance or deductibles you paid
  • What your insurance is covering
  • Who/how much has been paid

This information should match what you received from the hospital you visited – make sure to cross-reference them!

There are several factors that may affect the cost of your visit to the emergency room, including supply and demand, the reputation of the hospital, and the Charge Description Master (CDM) lists. A CDM contains any charge that a hospital may put on your bill, ranging from prescription drugs to services they provide. These typically do not reflect the actual cost that you will be obligated to pay, but are used for negotiating prices with insurance companies. Hospitals are required to make this information available to the public. 

After you receive your bill, make sure to look over the following items to ensure that the charges are correct:

  • Dates/number of days in hospital
  • Double charges
  • Number errors
  • Medicine charges
  • Cancelled work
  • Tests/procedures
  • Routine supply charges

Ways to Save at the ER

In addition to checking your ER bill, there are countless other ways for you to save money on your next visit to the emergency room. 

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1. Urgent Care Centers

Urgent care centers are often equipped to handle many of the medical surprises people tend to go to the ER for. It's important to remember that your insurance company is only required to cover the cost of your ER visit if it was an emergency situation. Minor conditions could be deemed as not emergent, and you would be responsible for more of the cost. In addition to saving money, visiting an urgent care will most likely save you time as well. Some conditions urgent care centers frequently treat include:

  • Broken bones
  • Cuts that need stitches
  • Burns
  • Vomiting
  • UTIs
  • Allergic reactions
  • And more!

An additional way that you can save at urgent care is by signing up for Mira. For an average of $45 a month, members at Mira get access to low-cost urgent care visits. In addition, you’ll also get access to $25 virtual care, up to 80 percent off over 1000 different prescriptions, and same-day lab testing. 

2. Check to See Fair Prices

If you had a procedure or surgery done at an ER, you can check to see if your hospital has charged you a fair price for the service. Several online websites have databases of medical service costs to give you an average cost of the procedure in your area. If the estimated cost is higher than what you were billed for, you can use this information to dispute and ask for a lower price. Two websites you can use are:

3. Ask Questions

Another way you can save is by asking the healthcare professionals in the ER questions about what they are doing. If you need to get a test or procedure done, make sure it is absolutely necessary for your condition, otherwise you could be paying unnecessary fees. Especially if you are in a non-emergent situation, these tests will end up costing more than if you went to see your primary care provider.

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4. Have Medical History On Hand

Before you make your trip to the emergency room, make sure to grab or make note of any pertinent medical history. This includes pre-existing medical conditions, medications you are taking, family history, and more. Knowing these facts off the top of your head will help the doctor assess you more properly, and could help to avoid unneeded tests or procedures. This will end up saving you both time and money.  

5. Negotiate Medical Bills

After you have checked through the itemized bill the insurance company or hospital has sent you, you may find some inaccuracies in billing. If that is the case, you are able to refute and negotiate your medical bills. If you are not feeling equipped to do this on your own, you can get help from a professional to do so. There are many experts out there that are trained in finding mistakes on medical bills and know where to look to find possible negotiations. Although it costs money, this may be a good option if you aren’t feeling confident about asking for a lower price yourself.  

Bottom Line

Emergency room visits can be very expensive, especially if your situation isn’t actually an emergency. In general, insurance companies will cover the cost of your visit to the ER (minus deductibles or copays), as long as your condition is deemed emergent. After visiting the emergency room, you should double check your bill and look for inaccuracies to make sure you were charged a fair amount. You can compare to charge master lists online, or hire a professional to help you dispute the cost. 

Most of the time, people mistakenly go to the emergency room for a situation that is not an emergency. Don’t let that be you. Urgent care is an affordable and accessible alternative, which can be made even cheaper through a Mira membership. Starting at an average of $25 a month, Mira members get access to low-cost virtual and urgent care, up to 80 percent off over 1000 different medications, and same-day lab testing. Don’t wait to save – sign up for Mira today. 

Talor Bianchini

Talor graduated from Penn State University with a B.S. in Biobehavioral Health, and minors in Spanish and Diversity & Inclusion in May of 2022. She has a passion for health equity and diversity in health. In the future, Talor hopes to work in public health policy reform to help eliminate health disparities. She enjoys reading, cooking, and listening to podcasts in her free time.