Does Medicaid Cover Emergency Room Visits?

• by Christian Worstell
• August 3, 2023

There may be no other type of health care where insurance coverage is more critical than emergency room visits. After all, you’re less likely to be thinking about costs and coverage in the event of an emergency, when receiving quick care is top of mind. 

Fortunately for Medicaid beneficiaries, Medicaid covers emergency room visits.

When does Medicaid pay for ER visits?

Each state has two sets of Medicaid benefits: those that are required by the federal government to be offered (mandatory) and those that the state chooses to offer on its own (optional). Emergency room care is a mandatory benefit that Medicaid covers in every state.

How is emergency room care covered under Medicaid?

Although every state is required to provide Medicaid coverage of emergency room visits, the way this care is covered can vary by state. 

• Some states, such as Arizona, do not require Medicaid beneficiaries to pay a copayment upon visiting an emergency room. Other states, such as Georgia, may charge a flat $3 copayment for any emergency room visit.
  
  
• Other states, such as Alaska, may charge a 5% coinsurance of the Medicaid reimbursement amount for an emergency room visit. Some states, such as Colorado, may charge $4 for a visit that is determined to be an emergency and $6 for visits deemed to not be an emergency. 
  
  
• States may also impose certain restrictions on Medicaid emergency room coverage, such as needing prior authorization or a “medically necessary” designation by a doctor. 

We recommend that you contact your state Medicaid program for more information about how your emergency room visit may be covered by your state’s Medicaid program.

Will Medicaid pay for an ER visit out of state?

Emergencies can happen anytime, including when you’re visiting another state. 

There are four instances in which a state Medicaid program must provide coverage and care to a beneficiary who lives in another state. 

1. During medical emergencies
2. When the beneficiary’s health would be endangered by having to travel back to their home state
3. If the necessary services and resources are more readily available than they are in the beneficiary’s home state
4. When it’s commonplace for beneficiaries in one locale to receive medical services in a bordering state

If one of the above criteria applies to your emergency room visit, you will likely receive Medicaid coverage for the care. It should be noted that states have some broad flexibility in how they determine out-of-state payment rates. 

Is urgent care covered by Medicaid?

Whether or not Medicaid will cover care received at an urgent care clinic or other walk-in clinic will depend on the type of care you receive and the state you live in. 

For example, clinic services are an optional benefit that is left up to each state to cover at their own discretion, but physician services are a required benefit in every state. Your coverage may depend on whether the care you receive is considered a clinic service or a physician service. 

Rural health clinic services and federally qualified health center services are both required benefits in every state, so if your urgent care visit falls under either category, it would be covered by Medicaid. 

Most urgent care facilities in the U.S. accept Medicaid, but it’s always a good idea to ask prior to receiving any billable services. 

Medicaid-Medicare plans that cover emergency room care

Some Medicaid beneficiaries are also eligible for Medicare. Some “dual-eligible” beneficiaries may be able to enroll in a certain type of Medicare Advantage plan called a Dual-eligible Special Needs Plan, or D-SNP.

These plans are designed specifically for those who are eligible for both Medicare and Medicaid, and they can include benefits that are not traditionally offered by either Medicare or Medicaid.

If you are eligible for Medicare, speak to a licensed insurance agent to find out if Dual-eligible Special Needs Plans are available in your area and what they cover. 

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.

 

 

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