Emergency Room Copay: Insurance Coverage and Costs

Emergency room copays can be a significant expense, but the good news is that many insurance plans cover at least some of the costs.

Typically, insurance plans require a copay for emergency room visits, which can range from $50 to $500 or more, depending on the plan and the provider.

Not all insurance plans are created equal, and some may offer more comprehensive coverage than others. For example, a study found that 71% of employer-sponsored plans cover emergency room visits with a copay, while 29% cover them with a deductible.

Most people are not aware that their insurance plan may have specific requirements or restrictions for emergency room visits, such as needing to get pre-authorization before seeking care.

Emergency room costs can be confusing, but understanding how they work can help you prepare and avoid surprise bills. You should be charged in-network rates for most of the care you get at the ER, but you might be treated by someone outside your network.

Emergency room visits are subject to copays, coinsurance, and deductibles depending on your policy. This means you might have to pay a portion of the bill, even if you have insurance.

There are two occasions when you may receive a larger than expected hospital bill: if an out-of-network provider cares for you during a hospital visit or stay, or if your insurer deems your issue wasn’t an emergency.

Health insurance companies have contracts with hospitals and providers, 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.

The No Surprises Act, which took effect in 2022, protects you from being billed out-of-network fees related to your emergency care. This protection applies whether you have insurance through an employer, a Marketplace, or from the individual market.

You can appeal a surprise medical bill to your insurer, and usually, health plans allow two internal appeals and one external appeal. You can also ask the hospital if it will accept a reduced payment, such as the Medicare rate.

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.

Check all your ER bills and insurance reports carefully to ensure you're not being charged out-of-network fees related to your emergency care. The No Surprises Act, which took effect in 2022, protects you from being billed out-of-network fees.

A co-pay for a trip to the emergency room might be $100, while a co-pay for a trip to an urgent care center might be $25.

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

Emergency room visits are subject to copays, coinsurance, and deductibles depending on your policy.

A $100 co-pay is a common amount for a trip to the emergency room, but this can vary based on your insurance plan and the type of healthcare provider you see.

After you've met your deductible, some health plans are structured to have you pay a percentage of the total bill, commonly 20 percent.

You can always call your insurance company to make sure you know the ins and outs of your plan before heading to the emergency room.

Your insurance company has a list of healthcare providers they have a contract with, known as their network. If a provider or healthcare facility is considered in network, it means they have a contract with your insurance company.

You can still receive care from an out of network provider, but it will likely be a more expensive visit than if you chose to see an in network provider.

If you're admitted to an out-of-network hospital, you may have to pay higher coinsurance amounts.

Most of the time, you can still see an out of network provider, but it's worth checking if they're in network before making the move.

If you change health insurance providers, it's a good idea to check if your primary care physician and other healthcare providers are in network with your new insurance before switching.

You should be charged in-network rates for most of the care you get at the ER. Your health insurance will cover you for a trip to the emergency room, whether that hospital is in or out of network.

Check all your ER bills and insurance reports carefully to ensure you're not being billed out-of-network fees related to your emergency care. The No Surprises Act protects you from being billed out-of-network fees for emergency care, which took effect in 2022.

If you do receive a surprise medical bill, 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.

You can also 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.

Here are some steps you can take if you receive a surprise medical bill:

You'll want to carefully review your ER bills and insurance reports to ensure you're not being charged out-of-network fees. The No Surprises Act, which took effect in 2022, protects you from being billed out-of-network fees related to your emergency care.

If you're admitted to an out-of-network hospital, you may have to pay higher coinsurance amounts. Emergency room visits are subject to copays, coinsurance, and deductibles depending on your policy.

Some people may be exempt from copays, including kids under age 19, youth in foster care or court-ordered kinship care, and American Indians or Alaskan Native tribal members. You'll also be exempt if you're pregnant or have had a baby in the past 60 days.

You can use the BadgerCare Plus family size and income limit to determine if you'll have a copay. The limits are as follows:

If your family income is at or below the monthly limit based on family size, you won't have a copay.

You should be charged in-network rates for most of the care you get at the ER, but it's not always the case.

Out-of-network providers can bill you for whatever fee isn't covered by your plan, but the No Surprises Act, which took effect in 2022, protects you from being billed out-of-network fees related to your emergency care.

One in five emergency room visits results in a surprise medical bill, according to a Peterson-KFF study.

Check your hospital bill for any unexpected charges, and if you find you're getting charged out-of-network for part of the care, you can appeal it to your insurer.

Here's a step-by-step guide to appealing a surprise medical bill:

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