Does Healthcare Insurance Cover Emergency Room Visit?

An ER Visit can Cause Plenty Even If You are Fully Covered by Insurance

Insurances are the safety plans in which a person invests. These plans are helpful whenever that person faces any severe damage. The amount for damage is paid through these plans, and as a result, the victim is saved from getting broke. Similarly, there are health insurance plans as well. A person invests money by selecting the plan which is most suitable to him. Whenever there is a medical health emergency, these plans fully or partially cover the bill and make it easy for the patient.

Medical health insurance work in such a way that when a person opts for a plan and pays for it, afterward, if that person faced any health emergency and got his treatment done from either primary care, urgent care, or emergency room, he would talk to his insurance agent before paying the bill. If the health insurance plan covers the treatment he received, the patient would either have to pay a significantly less amount or no bill at all. It all depends on the plan and the treatments that they cover. Talking about health insurance plans, some terms should be mentioned whenever insurance plans are discussed.


A deductible is an amount that one person pays before his health insurance starts to pay for his medical bill.


It is the amount that patient pays after paying the amount of his deductible. Copay is that actual small amount that the patients pay instead of the whole bill if their health insurance covers that.


It is the amount that a patient pays after he completes paying the deductible.

Two significant types of insurance cover almost all the healthcare departments. Whether it is primary care, urgent care center, retail clinic, or emergency care, these plans are HMO and PPO plans.

HMO: it is an abbreviation of the health maintenance organization. This plan has specified the health care institutes into a category called in-network health care centers. The insurance agents meet with the doctors working in those centers are signing a contract with them. They pay a heavy amount to those doctors in advance and then mark them as members of their in-network health care centers. Those doctors treat the patient but do not demand the actual bill; instead, they only take the copay from the patient. The con of this plan is that it is available only in specific in-network health care centers.

PPO: it is an abbreviation of preferred providers organization. This plan has no specific health care centers under it. A patient can go to any hospital and get his treatment done, and still, his bill would be covered by his health insurance agency. The drawback of this plan is that he has to pay the whole amount mentioned in the bill when the patient gets his treatment done. Afterward, he would contact his agent, who will cut the copay amount and return the remaining amount to him.

Emergency Room Billing

The case of the emergency room is a bit different. It is specified for fatal emergencies. The services provided in the emergency room cost a lot. There are many reasons behind it.

  • Firstly, the staff of the emergency room is up to the notch. They are highly qualified and experienced doctors. They are ready to deal with any sort of situation and try their best to provide quality service to the patient.
  • Secondly, it comes to the services provided. Rare diseases are diagnosed and treated in the emergency room. Patients suffering from fatal diseases are treated. Sometimes, there comes a patient who is suffering from a contagious disease. There is a chance that the doctors treating those patients might get affected. They are putting their lives in danger. So the financial department of the emergency room makes sure that these doctors are paid enough according to the services they provide to the patients.
  • Thirdly, there comes advanced machinery. The machinery used in the emergency room is costly, and they are not readily available. Even operating those machines is not an easy task. Specific people are hired and paid by the emergency room’s finance department to operate them.
  • In the last, there comes the point of timings. The emergency room is functional all day and all night without any break. The staff over there works in shifts and are ready for any emergency at any time.

If we add all these things up, it makes sense to us that why emergency room bills are so high.

Emergency Room Health Insurance

We know that in the time of a severe fatal emergency, a patient has no other choice rather than going to the emergency room because he has to save his life. Considering this situation, the Affordable Care Act has clearly stated that there are no in-network or out-network health care services in the case of fatal emergencies. It does not matter if the person went into the emergency room, which lies in his insurance company’s network or not. The insurance company must help him in order to pay the bill.

Does It Fully Cover The Bill?

No, whatever the insurance plan is, it cannot fully cover the emergency room bill. It is because almost two-third of the doctors working in emergency rooms are not under any contract. They do not depend on the emergency room finance department to pay their fee. They charge separately and set the amount according to the treatment they are giving to the parents. Health insurance companies can have a contract with the finance department of the emergency room that can collectively control all the staff. The health insurance does not have separate contracts with the doctors who are working on their own. Moreover, it tends to happen that the equipment owner (CT scan) may charge his separate fee.

Ways To Reduce It

In this case, the patient should opt for the following options

  • First of all, if he has a non-fatal emergency, then he should not go to the emergency room. If his treatment can be done in urgent care so he should opt for urgent care.
  • The insurance agent would need valid reasons why a person specifically went to the emergency room and why he went to an ER, not in the network. The patient’s reasons would be listened to and then considering the emergency, and the insurance agents would decide whether to cover the billing or not.

These were the ways to reduce the bills that are covered by the insurance plans. What about the bills that are not covered? Here is a solution to that as well.

  • In such a situation, when a patient wants to get that bill reduced which is not covered by the health insurance. The patient should talk to his agent, who would further help him negotiate the bill with the doctor.