Common Questions

Does medicaid cover emergency room visits.

er visits with medicaid

  • by Christian Worstell
  • January 12, 2024

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.

Learn More About Medicare

Join our email series to receive your free Medicare guide and the latest information about Medicare and Medicare Advantage.

By clicking "Sign me up!” you are agreeing to receive emails from MedicareAdvantage.com.

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.

Compare plans today.

Speak with a licensed insurance agent

1-800-557-6059 | TTY 711, 24/7

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. 

  • During medical emergencies
  • When the beneficiary’s health would be endangered by having to travel back to their home state
  • If the necessary services and resources are more readily available than they are in the beneficiary’s home state
  • 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. 

Christian

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 [email protected] .

MarketWatch logo

Related articles

Original Medicare (Parts A and B) doesn’t cover routine dental or vision care. 2024 Medicare Advantage (Part C) plans can cover benefits Original Medicare doesn’t cover, but dental and/or hearing benefits may not be available where you live. Learn more and find out how to compare the plans and benefits available in your area. Read more

When you travel or move to another state, does your Medicare insurance go with you? Find out how Medicare works in other areas of the country and how to maintain the coverage you need. Read more

If you are not automatically enrolled in Medicare, you’ll need to have these documents and information on hand when you apply for Medicare benefits. Learn more about what you need to have ready when you apply. Read more

If your Medicare card is lost, stolen or damaged, you can get a replacement card from Social Security and the Railroad Retirement Board, or by calling Medicare or logging into your My Social Security online account. Read more

Things can get confusing when someone is eligible for both Medicare and employer-sponsored health insurance. We’re here to clear it up and help you understand what you should know concerning Medicare and employer coverage. Read more

Medicare can be complex and confusing. This guide covers the 2024 Medicare basics, including all the info about cost, coverage, enrollment and more. Read more

In some cases, you may be able to qualify for Medicare at age 62. Learn more about Medicare eligibility before age 65 and what it means for you. Read more

Discover how to perform everyday tasks using MyMedicare.gov, the official Medicare online user portal, including opening an account, logging in and using the Blue Button. Read more

DOM 1968 (Evergreen Medicare Guide Cover Small)

Join our email series to receive your Medicare guide and the latest information about Medicare.

Please enter your information to get your free quote.

er visits with medicaid

Thanks for signing up for our emails!

Your Medicare guide will arrive in your email inbox shortly. You can also look forward to informative email updates about Medicare and Medicare Advantage.

If you'd like to speak with an agent right away, we're standing by for that as well. Give us a call!

Enter ZIP code

You're on your way to finding a Medicare Supplement plan!

Compare your Medigap plan options by visiting MedicareSupplement.com

Emergency Medicaid

Emergency medicaid requirement, the complete guide to emergency services covered by medicaid.

Emergency services covered by Medicaid play a crucial role in ensuring that individuals have access to necessary medical care during times of crisis. Medicaid, a state and federal program that provides healthcare coverage to low-income individuals and families, offers coverage for a wide range of emergency services. Understanding the importance of these services, knowing what is covered, and navigating the Medicaid system can be vital for those who rely on this program for their healthcare needs.

Understanding the Importance of Emergency Services Covered by Medicaid

Emergency services covered by Medicaid are of utmost importance for individuals and families who might not have the financial means to afford medical care during emergencies. Without this coverage, many people would be left without the necessary medical attention, leading to potentially dire consequences. Medicaid serves as a safety net, ensuring that individuals have access to emergency services regardless of their financial situation.

What Are the Different Emergency Services Covered by Medicaid?

Medicaid covers a wide range of emergency services, which may vary slightly from state to state. However, the program typically covers the following emergency services:

  • Emergency room visits
  • Ambulance transportation
  • Emergency surgeries
  • Diagnostic tests and imaging
  • Emergency dental care
  • Emergency mental health services
  • Emergency prescription medications

It is important to note that Medicaid coverage for emergency services is not limited to these examples, and it is always advisable to consult the specific guidelines and regulations set by your state’s Medicaid program.

How to Determine If Your Emergency Service Is Covered by Medicaid

If you require emergency services and are covered by Medicaid, it is crucial to determine whether the specific service you need is covered. To do so, you can take the following steps:

  • Contact your Medicaid provider: Reach out to your Medicaid provider to inquire about the coverage for the specific emergency service you require. They can provide you with detailed information on what is covered and any associated costs or requirements.
  • Review your Medicaid plan: Carefully review your Medicaid plan documents, including the summary of benefits. This will outline the emergency services covered by your plan and any limitations or restrictions.
  • Consult with healthcare providers: When seeking emergency care, consult with healthcare providers and inform them of your Medicaid coverage. They can assist in navigating the system and ensure that the services provided are covered.

Tips for Navigating the Medicaid System for Emergency Services

Navigating the Medicaid system can sometimes be challenging, especially when it comes to emergency services. Here are some tips to help you navigate the system more effectively:

  • Keep your Medicaid card accessible: Always keep your Medicaid card with you, as you may need to present it when seeking emergency services.
  • Stay informed: Familiarize yourself with the Medicaid guidelines and regulations specific to your state. This will help you understand your rights and the services covered.
  • Seek assistance: If you encounter difficulties navigating the Medicaid system, reach out to local advocacy organizations or healthcare providers who specialize in Medicaid. They can provide guidance and support.
  • Maintain documentation: Keep records of all medical visits, bills, and correspondence related to your emergency services. This will be beneficial in case of any disputes or questions regarding coverage.
  • Ask questions: Do not hesitate to ask questions regarding your coverage and any associated costs. Understanding the terms and conditions of your Medicaid coverage can help you make informed decisions.

Common Misconceptions About Emergency Services and Medicaid

There are several common misconceptions surrounding emergency services covered by Medicaid. It is important to address these misconceptions to ensure individuals have accurate information:

  • Emergency services are only covered in certain situations: Medicaid covers emergency services for any condition that requires immediate medical attention, regardless of the cause or circumstances.
  • Coverage is limited to specific providers: While Medicaid may have a network of preferred providers, emergency services are covered regardless of whether the provider is in-network or out-of-network.
  • Emergency services require prior authorization: Unlike non-emergency services, emergency services do not require prior authorization from Medicaid. However, it is essential to notify your Medicaid provider as soon as possible after receiving emergency care.

The Future of Emergency Services Coverage Under Medicaid

The future of emergency services coverage under Medicaid is subject to ongoing changes and discussions. It is crucial to stay informed about any modifications or updates to the program, as these can impact the coverage and accessibility of emergency services. Monitoring legislative developments and staying engaged with advocacy organizations can help ensure that emergency services continue to be adequately covered by Medicaid.

Frequently Asked Questions about Emergency services covered by Medicaid

Q: are emergency room visits covered by medicaid.

A: Yes, emergency room visits are typically covered by Medicaid. It is essential to notify your Medicaid provider as soon as possible after receiving emergency care.

Q: Does Medicaid cover ambulance transportation during emergencies?

A: Yes, Medicaid generally covers ambulance transportation when it is necessary for emergency medical care. However, it is advisable to check with your Medicaid provider to confirm the specific coverage and any associated requirements.

Q: Can I receive emergency dental care under Medicaid?

A: Yes, emergency dental care is often covered by Medicaid. However, coverage may vary depending on the state and the specific emergency dental service required.

Q: Is emergency mental health care covered by Medicaid?

A: Yes, emergency mental health care is typically covered by Medicaid. It is important to consult your specific Medicaid plan and provider for details on coverage and any requirements.

Q: Do I need prior authorization for emergency services under Medicaid?

A: No, emergency services covered by Medicaid generally do not require prior authorization. However, it is crucial to notify your Medicaid provider as soon as possible after receiving emergency care.

Expert Advice on Emergency services covered by Medicaid

When it comes to emergency services covered by Medicaid, it is crucial to stay informed about the coverage provided by your specific Medicaid plan. Familiarize yourself with the guidelines and regulations, and reach out to your Medicaid provider or local advocacy organizations if you have any questions or concerns. By understanding your rights and the services covered, you can ensure that you receive the necessary emergency care when you need it the most.

Comments are closed.

  • Download PDF
  • Share X Facebook Email LinkedIn
  • Permissions

Medicaid Expansion and Avoidable Emergency Department Use—Implications for US National and State Government Spending

  • 1 School of Medicine, Department of Emergency Medicine, University of Washington, Seattle
  • 2 School of Public Health, Department of Health Systems and Population Health, University of Washington, Seattle
  • 3 Evans School of Public Policy & Governance, University of Washington, Seattle
  • Original Investigation Association of Medicaid Expansion With Emergency Department Visits by Medical Urgency Theodoros V. Giannouchos, PhD, MS; Benjamin Ukert, PhD; Christina Andrews, PhD JAMA Network Open

Expansion of Medicaid through the Affordable Care Act has been one of the most consequential health and social program reforms in recent decades. Since 2014, approximately 14 million low-income US individuals, most of whom were uninsured before, have gained health insurance coverage through Medicaid expansion alone. 1 Beyond increasing health insurance enrollments, Medicaid expansion has resulted in a net savings for participating states overall (largely owing to enhanced federal cost-sharing) and numerous economic and health benefits for enrollees. 2 However, there are lingering concerns about the ramifications of using a publicly funded coverage mechanism for a large proportion of the population for state and federal budgets.

A crucial question for many policy makers is whether Medicaid expansion offers value over alternative pathways to expand coverage, such as greater investment in subsidized insurance exchanges. However, answering this question largely hinges on the extent to which Medicaid expansion improves the efficiency of health care use and spending. Giannouchos and colleagues 3 examine whether Medicaid expansion was associated with improvements in the use of what is often one of the most expensive health care settings: the emergency department (ED). Their simple yet revealing study further contributes to the literature by noting that Medicaid expansion is a good value for states and is likely to reap long-term benefits in the form of better population health and lower health care spending.

In this study, the authors examined 80.6 million outpatient ED visits from the Healthcare Cost and Utilization Project State Emergency Department Databases and a difference-in-differences design to evaluate changes in the rate of outpatient ED use in 2 Medicaid expansion states (New York and Massachusetts) vs 2 nonexpansion states (Georgia and Florida) from 2011 to 2017. 3 Emergency department visits were stratified by severity using the New York University algorithm, which classifies visits based on their likelihood that the primary diagnosis will fall into 1 of 4 subgroups: (1) emergent, not preventable, (2) emergent but potentially preventable, (3) emergent but primary care treatable, and (4) nonemergent. Emergency department visits related to injuries and behavioral health conditions are also classified (or classified separately). Although no clear consensus exists on what proportion of ED visits are unnecessary, it is generally believed that a substantial number could be avoided with either better access to timely and high-quality ambulatory care (such as in the case of preventing exacerbations of chronic illness), greater attention to mitigating social determinants of health or, at least, shifting care to a less costly venue (such as an urgent care center).

The investigators found that Medicaid expansion was associated with a significant reduction in overall ED use by 4.7 visits per 1000 population. 3 Furthermore, this reduction was associated largely with changes in the subgroups of ED visits that are potentially avoidable, with greater decreases noted for the least severe conditions that are likely to be most avoidable and smaller decreases for higher severity conditions. Visits classified as nonemergent decreased by 1.5 visits per 1000 population, those classified as primary care treatable declined by 1.1 visits per 1000 population, and those classified as emergent, but potentially preventable declined by 0.3 visits per 1000 population (all statistically significant declines). Conversely, the authors noted no associations with visits classified as injuries and emergent, not preventable, which would not be expected to change owing to insurance coverage alone. Although the present study was limited to ED use, the apparent disproportionate reductions in nonemergent and primary care–treatable conditions are highly suggestive of greater access to alternative and less-costly sources of care. Accordingly, these results are largely consistent with the preponderance of studies that show increased access to preventive care, better continuity of care and management of chronic disease, and an overall decrease in unmet health care needs among low-income adults in states that expanded Medicaid vs those that did not. 4 , 5

Reducing unnecessary ED use has been a longstanding priority for state policy makers. Medicaid enrollees use the ED at higher rates than those with private insurance or who are uninsured. 6 Although Medicaid coverage clearly improves access to essential services relative to having no insurance, many Medicaid enrollees still experience persistent barriers in accessing high-quality and coordinated services and face poor social determinants of health, both of which are associated with avoidable ED use. Moreover, unlike private insurance, most Medicaid programs do not impose cost-sharing requirements for health care services used by enrollees, which lowers the opportunity cost for using the ED for Medicaid enrollees compared with individuals with private coverage. This situation may be why many studies on Medicaid coverage expansions demonstrate increased ED use. For example, the Oregon Health Insurance Experiment, a randomized clinical trial under which Medicaid coverage was expanded via lottery to a subset of low-income individuals in Oregon, found that ED visits increased by 40% in the first year and a half following enrollment. 7 It is, therefore, understandable that the outcomes of the ACA’s Medicaid expansion on ED use have been an area of intense study.

Although Giannouchos et al 3 found encouraging patterns of ED use, other studies have found the opposite. In particular, a 2019 study by Garthwaite et al, 8 which also used Healthcare Cost and Utilization Project data, but included 20 states and all ED visits (both outpatient ED visits as well as those leading to inpatient admission), found that ED use for deferrable conditions increased in expansion states relative to nonexpansion states, whereas those for nondeferrable conditions did not. The authors defined deferrable conditions as those that a panel of physicians believed were likely to be at the patient’s discretion, and nondeferrable conditions as those that were truly emergent and not likely to be discretionary. This latter study only examined data through 1 year postexpansion and, thus, may have observed an early uptick in ED use owing to pent-up demand. The study by Giannouchos et al 3 incorporates a 4-year time horizon but a more limited set of states, which could explain the variable results.

So, where does this study leave us on the question of whether Medicaid expansions improve value for states with respect to ED use? It appears that for some states, expanding Medicaid improves the efficiency ED use, resulting in fewer ED visits for conditions that may be prevented with better access to primary care. In other states, especially those that may have less ambulatory capacity to meet increased demand from newly enrolled Medicaid beneficiaries, ED visits may increase (at least initially). However, it is important to consider that better access to care and management of chronic disease may take years to manifest in the form of improved health and lower rates of avoidable ED visits. As a result, the long-term outcomes of Medicaid expansion associated with avoidable ED use should remain an area of ongoing inquiry as a meaningful indicator of the effectiveness of the ambulatory care system for Medicaid enrollees, as well as the overall health of the Medicaid population.

Published: June 14, 2022. doi:10.1001/jamanetworkopen.2022.16917

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Sabbatini AK et al. JAMA Network Open .

Corresponding Author: Amber K. Sabbatini, MD, MPH, School of Medicine, Department of Emergency Medicine, University of Washington, 1705 NE Pacific St, Box 357235, Seattle, WA 98195 ( [email protected] ).

Conflict of Interest Disclosures: None reported.

See More About

Sabbatini AK , Dugan J. Medicaid Expansion and Avoidable Emergency Department Use—Implications for US National and State Government Spending. JAMA Netw Open. 2022;5(6):e2216917. doi:10.1001/jamanetworkopen.2022.16917

Manage citations:

© 2024

Select Your Interests

Customize your JAMA Network experience by selecting one or more topics from the list below.

  • Academic Medicine
  • Acid Base, Electrolytes, Fluids
  • Allergy and Clinical Immunology
  • American Indian or Alaska Natives
  • Anesthesiology
  • Anticoagulation
  • Art and Images in Psychiatry
  • Artificial Intelligence
  • Assisted Reproduction
  • Bleeding and Transfusion
  • Caring for the Critically Ill Patient
  • Challenges in Clinical Electrocardiography
  • Climate and Health
  • Climate Change
  • Clinical Challenge
  • Clinical Decision Support
  • Clinical Implications of Basic Neuroscience
  • Clinical Pharmacy and Pharmacology
  • Complementary and Alternative Medicine
  • Consensus Statements
  • Coronavirus (COVID-19)
  • Critical Care Medicine
  • Cultural Competency
  • Dental Medicine
  • Dermatology
  • Diabetes and Endocrinology
  • Diagnostic Test Interpretation
  • Drug Development
  • Electronic Health Records
  • Emergency Medicine
  • End of Life, Hospice, Palliative Care
  • Environmental Health
  • Equity, Diversity, and Inclusion
  • Facial Plastic Surgery
  • Gastroenterology and Hepatology
  • Genetics and Genomics
  • Genomics and Precision Health
  • Global Health
  • Guide to Statistics and Methods
  • Hair Disorders
  • Health Care Delivery Models
  • Health Care Economics, Insurance, Payment
  • Health Care Quality
  • Health Care Reform
  • Health Care Safety
  • Health Care Workforce
  • Health Disparities
  • Health Inequities
  • Health Policy
  • Health Systems Science
  • History of Medicine
  • Hypertension
  • Images in Neurology
  • Implementation Science
  • Infectious Diseases
  • Innovations in Health Care Delivery
  • JAMA Infographic
  • Law and Medicine
  • Leading Change
  • Less is More
  • LGBTQIA Medicine
  • Lifestyle Behaviors
  • Medical Coding
  • Medical Devices and Equipment
  • Medical Education
  • Medical Education and Training
  • Medical Journals and Publishing
  • Mobile Health and Telemedicine
  • Narrative Medicine
  • Neuroscience and Psychiatry
  • Notable Notes
  • Nutrition, Obesity, Exercise
  • Obstetrics and Gynecology
  • Occupational Health
  • Ophthalmology
  • Orthopedics
  • Otolaryngology
  • Pain Medicine
  • Palliative Care
  • Pathology and Laboratory Medicine
  • Patient Care
  • Patient Information
  • Performance Improvement
  • Performance Measures
  • Perioperative Care and Consultation
  • Pharmacoeconomics
  • Pharmacoepidemiology
  • Pharmacogenetics
  • Pharmacy and Clinical Pharmacology
  • Physical Medicine and Rehabilitation
  • Physical Therapy
  • Physician Leadership
  • Population Health
  • Primary Care
  • Professional Well-being
  • Professionalism
  • Psychiatry and Behavioral Health
  • Public Health
  • Pulmonary Medicine
  • Regulatory Agencies
  • Reproductive Health
  • Research, Methods, Statistics
  • Resuscitation
  • Rheumatology
  • Risk Management
  • Scientific Discovery and the Future of Medicine
  • Shared Decision Making and Communication
  • Sleep Medicine
  • Sports Medicine
  • Stem Cell Transplantation
  • Substance Use and Addiction Medicine
  • Surgical Innovation
  • Surgical Pearls
  • Teachable Moment
  • Technology and Finance
  • The Art of JAMA
  • The Arts and Medicine
  • The Rational Clinical Examination
  • Tobacco and e-Cigarettes
  • Translational Medicine
  • Trauma and Injury
  • Treatment Adherence
  • Ultrasonography
  • Users' Guide to the Medical Literature
  • Vaccination
  • Venous Thromboembolism
  • Veterans Health
  • Women's Health
  • Workflow and Process
  • Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

  • Register for email alerts with links to free full-text articles
  • Access PDFs of free articles
  • Manage your interests
  • Save searches and receive search alerts

Does Medicaid Cover ER Visits?

er visits with medicaid

Dec 19, 2022

Does Medicaid Cover ER Visits?

Emergency room care is a federally mandated Medicaid benefit.

Emergency room visits can be the most critical type of care. In the event of an emergency, you often don't have time to worry about your insurance and coverage, just that you or a loved one get the help that's needed. Fortunately, Medicaid does cover visits to the ER.

When will Medicaid cover ER visits?

Medicaid will always cover emergency room visits, but the way visits are covered varies depending on your state.

There are two sets of Medicaid benefits: mandatory benefits that the federal government requires, and optional benefits offered by the state. Emergency room care is a mandatory benefit, so no matter which state you live in you are covered. However, the type of coverage differs based on where you live.

Some states charge nothing for ER care, while others may charge a flat co-pay or percentage of the Medicaid reimbursement costs. There are even states that charge different prices based on whether your visit is deemed an emergency or not. It is always best to check with your state Medicaid program to see how, exactly, your care is covered.

What happens if I go to an out-of-state ER?

Medical emergencies are not limited to your home state, so it's understandable that many people worry about emergency room care being covered while they travel.

There are four scenarios in which Medicaid is required to provide ER coverage when visiting another state:

●      Traveling back to the home state would endanger the beneficiary's health

●      It is commonplace for beneficiaries to receive medical care in a bordering state

●      The required resources and services are more readily available than in the home state

●      During a medical emergency

If any of the above apply to your emergency room visit, Medicaid will usually cover your care the same as it would in your home state. But remember that some states have more flexibility in how they charge for out-of-state care. Pre-approved care at an out-of-state facility (properly authorized by Medicaid and a physician) may also be covered.

How do I know which type of health care facility to go to?

Sometimes, it can be confusing trying to figure out where you should go to receive medical care. You don't want to send yourself to the emergency room for a minor issue, but you also don't want to put off care for a more concerning and immediate medical problem. Below we go over when you should visit different types of health care facilities.

When to go to the emergency room

As indicated in the name, an emergency room should be used for medical emergencies . This includes, but is not limited to, severe trauma, broken bones, profuse bleeding, vehicular accidents, serious burns, and head injuries.

The purpose of an emergency room is to provide quick care for immediate issues. Care sought in an emergency room typically can only be done in a hospital setting at any time of day or night. Hence, the "emergency" title.

When to go to urgent care

Many people think of urgent care as synonymous with emergency rooms, which makes sense, as medical emergencies require urgent care. However, urgent care should not be treated the same as an ER for a few reasons.

First, many are not open 24/7 the same as emergency rooms. Heading for an urgent care center during an emergency, only to find they are closed, will prolong the amount of time it takes to receive potentially life-saving care.

Second, urgent care facilities do not have the same resources or staff as an ER to handle more complex medical issues.

An urgent care should be your choice when you need same-day care and cannot get in to see your primary care physician. Sprains/strains, minor cuts, mild flu-like symptoms, and vomiting are all reasonable things to go to urgent care to deal with.

When to schedule an appointment with your primary care doctor

Outside of an emergency, it is always best to consult your primary care physician for medical issues. They know your medical history and are well-equipped to help with non-emergency services and care options. Minor cold symptoms, annual wellness visits, and lab work are all care services you should try to schedule with your primary care doctor. If you can get in in a timely manner, the conditions listed above for urgent care would also be good to see your primary care doctor for.

When to call 911

It is not uncommon for people to be unsure of whether to call 911. Ambulance services can be expensive and you may not be entirely sure if an ambulance ride is warranted. In general, you should never drive yourself anywhere if you have severe chest pain or bleeding, or find your vision blurring or fading.

If you or a loved one has had a heart attack or stroke, calling 911 is always the right decision. Paramedics will get you to an ER as fast as possible and may be able to provide life-saving care on the way. When in doubt, calling 911 is the best choice you can make.

Does Medicare cover ER visits?

Medicare also covers emergency room care through Medicare Part B . You typically have a co-payment for each ER visit and for each hospital service rendered. Once you've met your Part B deductible, you pay 20% of the Medicare-approved amount for services. You do not have to pay this copay if your doctor admits you to the same hospital within three days of your emergency room visit for a related issue. Your visit would be considered part of your inpatient stay at the hospital.

Additional reading

ClearMatch Medicare: Does Medicare Part A Cover Emergency Room Visits?

Internal link

ClearMatch Medicare: Does Urgent Care Take Medicare?

ClearMatch Medicare: What Does Medicaid Not Cover?

Find a Medicare Plan in your area

It’s FREE with no obligation

Speak with a Licensed Insurance Agent

M-F 8:00am-10:00pm | Sat 9:00am-6:00pm EST

RELATED ARTICLES

Medicare Donut Hole

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Advanced Search
  • Journal List
  • Popul Health Manag

Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data

Hyunjee kim.

1 Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon.

K. John McConnell

Benjamin c. sun.

2 Department of Emergency Medicine, Center of Policy Research–Emergency Medicine, Oregon Health & Science University, Portland, Oregon.

Associated Data

The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid–commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011–2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid–commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid–commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.

Introduction

T he high rate of emergency department (ED) use by Medicaid enrollees has been a long-standing concern among policy makers. 1–4 State Medicaid programs have proposed different policies to reduce ED visits including requiring Medicaid patients to make higher co-payments for their ED visits or providing Medicaid patients with robust alternative services to ED care through patient-centered medical home models. 5 However, those policies may have limited effectiveness if they are based on incorrect assumptions about the underlying reasons for high rates of ED use in the Medicaid population.

A variety of factors may explain differences in ED use among Medicaid and commercial patients. Medicaid enrollees have a higher comorbidity burden 1 , 6 , 7 and are more likely to experience primary care access problems or unsatisfactory primary care. 6 , 8 , 9 Medicaid enrollees also might use the ED more frequently because they typically make minimal co-payments for ED visits, 1 or because they perceive the ED as a one-stop shop that provides multiple services simultaneously, an attribute appealing for patients who struggle with transportation. 10

There are several gaps in the knowledge of ED use among Medicaid beneficiaries. First, although high ED use is a visible target for policy makers, less is known about whether the Medicaid–commercial utilization difference is unique to the ED or if it persists across other types of health services. Second, although some studies have used survey data to explain the Medicaid–commercial difference in ED use, there have been fewer efforts to assess the extent to which ED use could be explained by Medicaid–commercial differences in observable factors such as patient demographics, comorbidities, neighborhoods, and proximities to services to explain differences. Third, although high ED use has often been viewed as a proxy for a lack of access to primary care, most studies have not been able to assess the impacts of different care by different primary care providers (PCPs). The final question is important because simple measures of primary care access may obscure differences in the quality or thoroughness of care by PCPs.

This study bridges these gaps using Oregon's All Payer All Claims (APAC) database. These data allow for 3 contributions that are highly relevant to policy development around ED use. First, APAC data allow for the observation of Medicaid and commercial patients' differences in utilization not only in ED care, but in other services as well. Second, these data allowed the assessment of whether Medicaid and commercial differences in ED use are consistent across different types of ED visits, including low- and high-severity ED visits. These analyses may help elucidate policies that are more effective in reducing ED visits for primary care treatable conditions. Third, by using provider identification information for each claim in the data, this study examined the influence of each Medicaid and commercial patient's PCP on ED use. These analyses are particularly valuable because PCPs may differ in their efforts or capacity to help patients receive the care they need without using the ED.

In sum, this study compared ED use by Medicaid and commercially insured patients. These groups account for the largest shares of ED patients aged 18 to 64 years. 2 , 11 Specifically, this study aims to: (1) provide context for ED service use by comparing Medicaid–commercial differences across ED and non–ED health service use, and (2) assess the extent to which differences in ED use by Medicaid and commercial patients can be explained by observable factors.

Study design

This study implemented the non-linear Blinder-Oaxaca decomposition of Medicaid–commercial differences in ED visits using 2011 to 2013 data from the Oregon APAC database. 12 More specific explanation of the non-linear Blinder-Oaxaca decomposition methods will be provided in the primary data analysis section. The APAC data include all Medicaid and commercially insured enrollees residing in Oregon and their medical claims. The exception is enrollees in commercial self-insured plans that cover fewer than 5000 enrollees; the APAC database includes approximately 87% of commercially-insured individuals in the state. 13 Claims related to substance abuse were excluded to comply with federal regulations. 14 Institutional review board approval for this study was received from Oregon Health & Science University.

Selection of participants

This study included all Medicaid and commercially-insured enrollees extracted from the 2011–2013 data from the Oregon APAC database. Children aged 0–18 years were excluded because pediatric ED visits are likely to be highly correlated with parent ED visit behaviors. 1 Further exclusions were enrollees who were ages 65 years or older or were eligible for Medicare because no information was available on health service use paid by Medicare, and enrollees who were not covered by Medicaid or commercial insurance throughout each entire calendar year because changes in insurance status may be associated with changes in ED utilization patterns. 13 The final data set included 2,586,173 patient-year observations, with Medicaid beneficiaries accounting for 13.2% of the total sample. See Supplementary Table S1 (Supplementary Data are available in the online article at www.liebertpub.com/pop ) for characteristics of beneficiaries in the sample.

Outcome measures

The outcome variables included dummy variables indicating whether a patient used ED care, mental health care, and inpatient care at least once during the year. In addition, 3 separate types of ED visits were examined: (1) ED visits that resulted in an inpatient admission to the hospital, (2) high-severity ED visits, and (3) low-severity ED visits. Note that these are not mutually exclusive categories. High- and low-severity ED visits were constructed based on the algorithm developed by Billings et al. 15 The algorithm calculates probabilities for 4 categories based on each visit's primary diagnosis: non-emergent; emergent yet primary care treatable; emergent and ED care needed yet preventable; and emergent and ED care needed and not preventable. A visit was defined as high severity if the sum of the probabilities of the last 2 categories was at least 0.75 and low severity if the sum was less than 0.25, an approach validated in other studies. 16–19 These severity categories were not used to assess the appropriateness of ED visits, but rather to identify ED visits that could have been treated in a primary care setting. ED visits with injury and mental health diagnoses were not captured with the algorithm and were excluded in defining low- and high-severity ED visits. Supplementary Table S2 lists the 5 most common primary diagnoses for each type of ED visit across Medicaid and commercial insurance patients. As a sensitivity analysis, an indeterminate-severity ED visit (a visit with the sum of the probabilities between 0.25 and 0.75) 16–18 was created and the same analysis was conducted.

Observable factors

Each patient's age, sex, and rurality (based on zip code of residence) were considered to be potential contributing factors to the Medicaid–commercial difference in ED visits. 20 Also taken into account were each patient's health conditions, including pregnancy status and 17 chronic health conditions. The health conditions were extracted from the Chronic Illness and Disability Payment System (CDPS), which has been validated and used for risk adjustment in Medicaid populations. 21 , 22 Patients' health service use also was considered, including whether each received primary care and mental health care at least once a year.

Observable factors also included patients' neighborhood characteristics, including percentages of the population below the poverty level, college graduates, and African American and Hispanic residents based on zip code of residence, extracted from the 2011 American Community Survey. 23 For a proxy measure of access to primary and specialty care, this study used the number of primary care and specialty physicians per patient in each patient's hospital service area, extracted from the Area Health Resources File. 24 To control for access to the ED, the distance in miles from the patient's residence to the nearest ED was calculated using zip codes and an indicator of ≥25 miles distance to the nearest ED was created. Finally, year dummies were included to control for changes in ED visits over time.

Primary data analysis

A non-linear version of the Blinder-Oaxaca decomposition was used to analyze the influence of each observable factor on the Medicaid–commercial difference in ED visits. 25 The Blinder-Oaxaca decomposition has been widely used to explain differences between groups, including the wage difference between whites and blacks, the health insurance coverage difference across children with different ethnicities, and specialty care referral differences between men and women. 26–28

This technique was used to decompose the Medicaid–commercial difference in the average level of ED use into 2 parts. The first part ( explained difference ) is the difference in ED use attributable to differences in factors across Medicaid and commercial patients that are observable in the APAC database. These observable factors include patients' demographics, health conditions, neighborhood characteristics, distance to the nearest ED, and selection of PCPs. This first part enables the analysis of the relative contribution of each observable factor to the difference in ED use.

The second part ( unexplained difference ) is the difference in ED use not captured by observable factors. The second part captures factors affecting ED use that cannot be observed in the database, such as unobserved differences in behavior between Medicaid and commercial enrollees or differences in providers' treatment of Medicaid versus commercial patients. For example, Medicaid patients' tendency to use the ED as a “one-stop health care shop” would be captured as a part of the unexplained difference.

Because of the binary nature of the outcome variables, a non-linear version of the Blinder-Oaxaca decomposition was used, the Fairlie decomposition. 25 Both Medicaid and commercial patients were used and a logit regression of their ED use was estimated. The contribution of each factor was then calculated using coefficients from the logit regression with observable factors randomly ordered. As a sensitivity analysis, coefficients from 2 separate regressions were used with a separate sample of Medicaid and commercial groups and the relative contribution of each factor was calculated.

Three sets of decomposition analyses were conducted. The first examined the influence of observable factors on multiple types of health service use by Medicaid and commercial patients. The outcome measures for these analyses included any ED, mental health, and inpatient use at least once a year. These analyses enabled the assessment of whether a large difference in ED use by Medicaid and commercial patients is also seen in other services. Primary care use was not examined in this analysis because the Medicaid–commercial difference in any primary care use was negligible (less than 1 percentage point). The second set of analyses switched the focus to ED care and examined the extent to which observable factors explained the Medicaid–commercial difference in ED visits including any ED visits, high-severity, low-severity, and ED visits resulting in an inpatient admission.

The third set of analyses included PCP “fixed effects” as another observable factor in the model to examine the relative importance of each patient's choice of specific PCP on the patient's ED visits. This fixed effects model included a dummy variable for each separate PCP (identified through the National Provider Identifier). In this manner, the model controlled for unobserved factors specific to each patient's PCP, going beyond a simple measure of access to primary care. For example, Medicaid patients might have access to primary care but be cared for by low-quality providers, leading patients to visit the ED even for primary care treatable conditions. Provider identification information was used to assign 1 PCP to each patient. For patients who visited multiple PCPs a year, the PCP a patient visited the most was selected. Only those PCPs who treated at least 150 patients a year were included to avoid perfect prediction in logit regressions. Based on these additional sample selection criteria, 772,143 patient-year observations treated by 1283 PCPs were used for the third analysis. As another sensitivity analysis, this sample's ED utilization was compared that of the original sample.

All statistical analyses were performed using Stata, version 13 (StataCorp LP, College Station, TX).

Table 1 displays the results of the decomposition analyses for different health services. The first 2 rows display the probability that Medicaid and commercial patients used each type of health care at least once a year. The Medicaid–commercial difference in ED visits was substantially greater than the difference in mental health and inpatient care. A substantial difference also was found in what observable factors could explain in the difference in ED use as compared to other services. Observable characteristics explained only 43.8% of the difference in ED visits while the corresponding values for mental health and inpatient care were 82.6% and 74.7%, respectively.

Decomposition Analysis of Difference in Use of Emergency Department, Mental Health, and Inpatient Care Between Medicaid and Commercial Patients (n = 2,586,173)

ED, emergency department.

The first 2 rows in Table 2 display descriptive statistics for Medicaid and commercially insured adults' ED visits. Approximately 44.5% of Medicaid patients visited the ED at least once a year, about 4 times more than commercial patients. This gap was greater than the national average in 2013, when 38.0% and 14.1% of Medicaid and commercial patients, respectively, visited the ED. 2 Medicaid patients were 7 times more likely to have a low-severity ED visit and 4 times more likely to have a high-severity ED visit or ED visit resulting in an inpatient admission.

Decomposition Analysis of Difference in Emergency Department Visits Between Medicaid and Commercial Patients (Pooled Coefficient) (n = 2,586,173)

CDPS, Chronic Illness and Disability Payment System; ED, emergency department; PCP, primary care provider.

The top reasons for each type of ED visits were similar between Medicaid and commercial patients ( Supplementary Table S2 ). The most common health conditions for low-severity ED visits include headache, back pain, and nausea/vomiting, which could possibly be managed in primary care settings. In contrast, emergent health conditions such as urinary tract stones and cardiac dysrhythmia were the main diagnosis for high-severity visits.

The remaining rows in Table 2 display detailed decomposition results for various types of ED visits, showing the relative contribution of each observable factor to the difference in ED visits between Medicaid and commercial patients. For simplicity, only the relative contribution of each factor in percentage terms is reported. Supplementary Table S4 provides the complete set of decomposition estimates and their standard errors. Supplementary Table S3 provides logit regression estimates used to calculate decomposition estimates in Supplementary Table S4 .

Observable factors explained 15 out of 34 percentage points of total difference in any ED visit, indicating that less than a half (15/34 × 100 = 43.8%) of the Medicaid–commercial difference in any ED visits was explained by observable factors. The Medicaid–commercial difference in age composition explained 0.0215 out of the total 0.34 percentage point difference in any ED visits ( Supplementary Table S4 ), indicating that 6.4% of the total difference in ED visits (0.0215/0.34 × 100≈6.4%) was explained by differences in age composition. As another example, the Medicaid–commercial difference in the distance to the nearest ED (≥25 miles to ED) explained −0.0004 of the total difference in any ED visits, explaining −0.1% of the difference in ED visits (−0.0004/0.34 × 100≈−0.1%). This negative value indicates that Medicaid patients' further distance from the ED (as compared to commercial patients') was actually associated with lower rates of ED visits.

Health conditions measured by CDPS indicators explained the greatest amount (30.3%) of the Medicaid–commercial differential. Primary care visits explained only a small portion of the difference in ED use (0.3%), perhaps because Medicaid and commercial patients had similar rates of primary care use. Neighborhood characteristics and provider availability explained less than 4% of the difference.

The total differences for high-severity and inpatient visits were relatively small (0.040 and 0.041 percentage points, respectively) compared to the difference for any low-severity visits (0.22 percentage points). Observable factors explained a greater portion of the difference in high-severity and ED visits resulting in inpatient admissions (73.0% and 86.7%, respectively) than low-severity ED visits (47.7%). The prevalence of health conditions, as captured by the CDPS indicators, explained the largest proportion of differences in use.

Table 3 displays decomposition results with and without PCP fixed effects. This analysis restricted the sample to patients with at least 1 primary care visit and decomposed the Medicaid–commercial difference, controlling for each patient's specific PCP. Inclusion of PCP fixed effects increased the share of the explained Medicaid–commercial difference for any ED visit by 8.1%, from 49.6% without fixed effects to 57.7% with fixed effects. A similar phenomenon was found for low-severity ED visits, with the explained share increasing by 8.7%, from 53.4% without fixed effects to 62.1% with fixed effects. By contrast, the inclusion of PCP fixed effects increased the explained share for high-severity ED visits by only 1.5 percentage points and decreased the explained share by 0.5% for ED visits resulting in an inpatient admission. In sum, each patient's selection of PCP explained a greater portion of the difference in low-severity ED visits than in high-severity ED visits or those resulting in an inpatient admission. Supplementary Tables S5 and S6 provide the full decomposition results for these models.

Decomposition Analysis of Differences in Emergency Department Visit Between Medicaid and Commercial Patients with Primary Care Provider Fixed Effects Included and Excluded on the Restricted Sample (n = 772,143)

ED, emergency department; PCP, primary care provider.

As a sensitivity analysis, the same decomposition analysis was conducted for any indeterminate ED visit ( Supplementary Table S7 ). Results revealed that observed factors explained 58.9% of the Medicaid–commercial difference, which was between explained shares for high- and low-severity ED visits. Another sensitivity analysis used coefficients from the regression with a separate sample of Medicaid and commercial insurance enrollees for decomposition and found that the basic patterns stayed the same ( Supplementary Tables S8 and S9 ). Finally, a subset of patients included in the decomposition with PCP fixed effects was examined and it was found that they had similar ED use patterns ( Supplementary Table S6 ).

Using newly available APAC data, this study found that the Medicaid–commercial difference in ED care was substantially greater than the difference in mental health and inpatient care, further highlighting the disproportionately high rates of ED use among Medicaid patients. Decomposition methods could explain the majority of the Medicaid–commercial difference for mental health and inpatient care services, but ED care was an exception. In other words, unobserved factors played a more important role in explaining ED use than other services among Medicaid patients.

Among observable factors, health conditions explained the greatest portion of the difference in any ED visits. This result suggests that effective interventions to reduce ED visits among Medicaid enrollees would include providing alternative health services for enrollees with health conditions such as case management, regular primary care, and access to urgent care. With the exception of age, other demographic factors accounted for relatively little of the difference in ED use. Given that the youngest group of enrollees' (aged 19 to 24 years) had the highest likelihood of ED visits ( Supplementary Table S3 ), and that a large amount of the ED use difference was explained by patients' age, the ED use patterns of younger Medicaid enrollees deserves particular attention.

The amount of the difference explained by observable factors was substantially higher for high-severity ED visits and those resulting in an inpatient admission than for low-severity visits. That is, unobservable factors were more likely to drive low-severity ED visits as compared to other types of ED visits. This discrepancy was primarily driven by the greater relevance of CDPS risk indicators in explaining high-severity and inpatient visits. In other words, the Medicaid–commercial difference in health conditions was a considerably more important factor for high-severity ED visits and those resulting in an inpatient admission than for low-severity ED visits.

Having at least 1 PCP visit a year explained only a small portion of the Medicaid–commercial difference in ED use, potentially driven by similarly high rates of PCP use among Medicaid and commercial patients. However, including information about each patient's specific PCP (through PCP fixed effects) increased the portion of the explained difference, particularly for low-severity ED visits. There could be several possible explanations for this positive correlation between a patient's PCP and low-severity ED visits. If Medicaid patients were seen primarily by busy or under-resourced PCPs who could not cater to all of their needs, these patients might be more likely to visit the ED for primary care treatable conditions. The availability of PCPs may vary broadly, with some PCPs offering extended evening and weekend services and same-day appointments and others restricting their scheduling and availability. 29 , 30 PCPs also may differ in their comprehensiveness of care. 30 , 31 Overall, this study's results confirm an important role for Medicaid patients' PCPs in reducing low-severity ED visits. By contrast, controlling for each patient's PCP only slightly increased the explained portion of the difference in high-severity ED visits and barely changed the corresponding portion for ED visits resulting in an inpatient admission. This suggests that the more discretionary the nature of the ED visit, the greater was the relevance of the patient's PCP in driving higher ED use among Medicaid enrollees.

The unexplained difference in ED use between Medicaid and commercial patients could be attributed to multiple factors. Medicaid patients might visit the ED more frequently because they face minimal or no co-payments, while commercial patients face higher co-payments. However, the cost sharing differential between Medicaid and commercial patients exists across most of the health services explored, including mental health visits, inpatient hospitalization, high-severity ED visits, and ED visits resulting in an inpatient admission, where Medicaid–commercial differences were relatively small. Thus, it is not clear if the cost sharing differential accounts for the large difference in ED use between Medicaid and commercial patients.

Alternatively, Medicaid patients may have been acculturated to use the ED frequently because the ED can address patients' health care needs all at once and it requires no prior appointments. 30 , 32 Other unobserved factors might include patterns in how providers treat Medicaid patients. Although providers could relatively easily refuse or postpone treatments of Medicaid patients in a mental health, inpatient, and primary care setting, ED providers are mandated to provide care to all patients who present in the ED regardless of their insurance status under the Emergency Medical Treatment and Active Labor Act. Additionally, the patient's social determinants of health such as housing instability, food insecurity, or lack of transportation availability could be important factors contributing to higher rates of ED use for Medicaid enrollees. 32 This would imply that potential interventions for ED use reduction might need to occur outside of the health system. Finally, policy changes such as the introduction of coordinated care organizations in Oregon's Medicaid program or increased insurance coverage through health insurance exchanges could be another unobserved factor, although the year dummy variables controlled for this trend to some degree.

There are several limitations to this study. First, a large portion of the difference in ED visits could not be explained, particularly low-severity ED visits, with health claim information from the database. This suggests that extra data sources might be needed to fully understand contributing factors to the ED use difference between Medicaid and commercial patients. Given the difficulty of obtaining additional data, however, the quest to accurately understand the factors contributing to high rates of ED use and devise effective policy options is indeed challenging, albeit worthwhile. Also, if unobserved factors were correlated with observable factors in the model, the size of the contribution of observable factors in the current model could be biased. Thus, the relationship between observable factors and ED use should be understood in terms of associations, not causal relationships. PCP fixed effects explained about 8% of the Medicaid–commercial differences in ED use. However, the individual PCP characteristics that may have contributed to the Medicaid–commercial differences in ED use could not be identified. Claims related to substance abuse were excluded, and therefore ED use related to substance abuse was not included in the analysis. However, this might lead to a conservative bias because Medicaid beneficiaries have shown much higher risk for substance abuse related ED visits than commercially insured beneficiaries. 33 Moreover, the data set used covers 2011 to 2013, prior to the Medicaid expansion starting in 2014, and therefore does not reflect newly enrolled Medicaid beneficiaries' ED use. Finally, the data are from Oregon; generalizability to other states could be limited.

Conclusions

Reducing rates of ED use among Medicaid patients continues to be an area of priority for states looking to control Medicaid costs. This study examined the extent to which observable factors at both the individual and community levels can explain differences in ED use. The results indicated that in addition to their higher disease burden, Medicaid patients' PCP choice was a significant factor in explaining higher rates of ED use, highlighting the important role of PCPs in reducing low-severity ED visits. The remaining unexplained difference suggests that ED use remains a fruitful target for policy makers, although success may require additional knowledge about patients' perceptions and behaviors as well as social determinants of health.

Supplementary Material

Author disclosure statement.

Drs. Kim and McConnell, and Mr. Sun declared no conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received the following financial support: NIH Common Fund Health Economics Program (1R01MH1000001) & Silver Family Foundation.

Having Medicaid increases emergency room visits

er visits with medicaid

Unique study on Oregon’s citizens sheds light on critical care in the U.S.

For immediate release: January 2, 2014

Boston, MA — Adults who are covered by Medicaid use emergency rooms 40 percent more than those in similar circumstances who do not have health insurance, according to a unique new study that sheds empirical light on the inner workings of health care in the U.S.

The study takes advantage of Oregon’s recent use of a lottery to assign access to Medicaid, the government-backed health-care plan for low-income Americans, to certain uninsured adults. The research examines emergency room records for roughly 25,000 people over 18 months.

“When you cover the uninsured, emergency room use goes up by a large magnitude,” says Amy Finkelstein, the Ford professor of economics at MIT and a principal investigator of the study, along with [[Katherine Baicker]], professor of health economics at Harvard School of Public Health.

The study, published January 2, 2014 in the journal  Science,  also documents that having Medicaid consistently increases visits to the emergency room across a range of demographic groups, types of visits, and medical conditions, including types of conditions that may be most readily treatable in primary-care situations.

“In no case were we able to find any subpopulations, or type of conditions, for which Medicaid caused a significant decrease in emergency department use,” Finkelstein adds. “Although one always needs to be careful generalizing to other settings, these results suggest that other Medicaid expansions are unlikely to decrease emergency room use.”

What’s the policy upshot?

The study is highly relevant to the current landscape in the U.S.: With the implementation of the Affordable Care Act , Medicaid is expanding in many states to cover a population similar to the one that gained Medicaid through Oregon’s lottery. The results in this paper, however, suggest nuances to the current debates over the expansion of Medicaid, medical costs , and the role of emergency rooms in providing care.

On one level, the results accord with a traditional economics framework suggesting that insurance, by lowering out-of-pocket costs, would increase the use of medical care. Or, as Finkelstein observes, “If we’ve lowered the price of the emergency department, we would expect people to use it more.”

However, Medicaid also lowers the out-of-pocket costs of other types of health care, such as primary-care doctors. Some policy analysts have suggested that expanding Medicaid could reduce emergency department visits by the formerly uninsured by bringing them into more regular contact with primary-care doctors and clinics for preventive care. In theory, that could also reduce overall system costs, since urgent care is expensive.

Indeed, prior work by Finkelstein, Baicker, and others on Oregon’s lottery applicants showed that people who obtain Medicaid increase their use of primary and preventive care. But as Finkelstein points out, the net effect of Medicaid in the study was to also increase use of emergency services.

Hypothetically, Finkelstein notes, the results “could have gone either way, which makes empirical work all the more important.”

Lottery numbers

The study’s rigor derives from a unique policy the state of Oregon implemented in 2008. State officials, recognizing that they had Medicaid funds for about 10,000 additional low-income adults, developed a lottery to fill those slots, for which about 90,000 Oregonians applied.

From the viewpoint of academic researchers, the lottery system presented the opportunity for a randomized controlled evaluation of Medicaid, since it created a group of state residents obtaining Medicaid coverage who were otherwise similar, on aggregate, to the applicants who continued to lack coverage.

“It’s not that we’re the first to look at the effects of Medicaid empirically, but we are the very first to have a randomized controlled trial of the effect of covering the uninsured with Medicaid,” Finkelstein says.

In Oregon, uninsured adults are eligible for the lottery-based Medicaid program when their annual income falls below the federal poverty level established by the U.S. Department of Health and Human Services, which in 2013 is roughly $11,490 for a single person or $23,550 for a family of four.

In addition to Finkelstein and Baicker, the co-authors of the  Science  paper, titled “Medicaid Increases Emergency Department Use: Evidence from Oregon’s Health Insurance Experiment,” were lead author Sarah Taubman of the National Bureau of Economic Research, Heidi Allen of Columbia University’s School of Social Work, and Bill Wright of the Center for Outcomes Research and Education at Providence Health and Services in Portland, Ore.

It is the latest paper to emerge from an ongoing study, led by Finkelstein and Baicker, of the lottery applicants in Oregon’s Medicaid system. In a 2011 paper published in the  Quarterly Journal of Economics , they showed that Medicaid coverage increases doctor visits, prescription drug use, and hospital admissions; reduces out-of-pocket expenses or unpaid medical debt; and increases self-reported good health. In a 2013 paper published in the  New England Journal of Medicine , they showed that Medicaid coverage reduces the incidence of depression but does not produce measured improvements in physical health.

Finkelstein says she has been motivated by the Oregon study, and its reception, to create a new research group, J-PAL North America. Co-founded with Harvard economist Lawrence Katz, the group is meant to encourage randomized evaluations on policies and social issues in the U.S. It is the newest branch of MIT’s Abdul Latif Jameel Poverty Action Lab, which was founded in 2003 to support randomized trials in development economics globally.

“It’s relatively rare to have this kind of randomized controlled trial on a major [policy] issue,” Finkelstein says. “And I’d like that to become less the exception, and closer to the norm.”

Written by Peter Dizikes, MIT News Office

For more information:

Todd Datz, HSPH 617.432.8413 [email protected]

Abby Abazorius, MIT 617.253.2709 [email protected]

Expanding Medicaid lowers rates of depression, reduces financial strain, but no improvement shown in physical health (May 2013)

Harvard School of Public Health brings together dedicated experts from many disciplines to educate new generations of global health leaders and produce powerful ideas that improve the lives and health of people everywhere. As a community of leading scientists, educators, and students, we work together to take innovative ideas from the laboratory and the classroom to people’s lives—not only making scientific breakthroughs, but also working to change individual behaviors, public policies, and health care practices. Each year, more than 400 faculty members at HSPH teach 1,000-plus full-time students from around the world and train thousands more through online and executive education courses. Founded in 1913 as the Harvard-MIT School of Health Officers, the School is recognized as the oldest professional training program in public health.

  • Share full article

A 1-yea- old boy, held by his mother, who wears a face mask, is having his ear examined with a device held by a doctor, also wearing a mask, in a colorful clinic.

As Medicaid Shrinks, Clinics for the Poor Are Trying to Survive

The end of a pandemic-era policy that barred states from pushing people off Medicaid is threatening the financial stability of the U.S. safety net.

A child who had been diagnosed with respiratory syncytial virus and pneumonia visited with Dr. Danny Price, left, at Bethesda Pediatrics in Tyler, Texas. Credit...

Supported by

Noah Weiland

By Noah Weiland

Photographs by Desiree Rios

Noah Weiland, who is covering the shrinking of Medicaid enrollment around the country, reported from a pediatric clinic in Tyler, Texas.

  • Published Feb. 24, 2024 Updated March 1, 2024

Appointment cancellations and financial distress have become a constant at Bethesda Pediatrics, a nonprofit medical clinic in East Texas that is heavily dependent on Medicaid, the health insurance program for the poor.

On a recent Monday, the mother of a toddler who had a primary care appointment broke down in tears after learning the child had just lost Medicaid coverage, wondering how she could pay the bill.

Another mother told Dr. Danny Price, the clinic’s lead pediatrician, that she was afraid to get her child a flu shot because of the $8 fee she would have to pay now that the child had been dropped from Medicaid.

A child with depression did not show up, most likely, Dr. Price presumed, because of having lost Medicaid coverage.

The uncertainty and panic at the clinic, tucked inconspicuously in a poor residential pocket of Tyler, Texas, highlight a little-examined consequence of the vast trimming of the Medicaid rolls since a policy that barred states from kicking anyone out of the program during the pandemic ended last spring . The loss of coverage has not only affected families, but is also threatening the financial stability of vital components of the American safety net.

Medicaid payments are “the lifeblood of our health centers and their ability to serve,” said Dr. Kyu Rhee, the president and chief executive of the National Association of Community Health Centers, which treat roughly one in 11 people in the United States and rely on Medicaid and federal grants to provide a financial cushion for the uncompensated care they give uninsured patients.

Since last spring, Medicaid enrollment has dropped by almost ten million, including around four million children, according to researchers at Georgetown University. States have removed people for a variety of reasons, including for changes in income and age. Some people have been dropped because they did not return paperwork. Others have lost coverage because of technical errors, including computer glitches.

The loss of reimbursements for millions of patients has contributed to an already difficult financial picture for facilities that treat the poor: Unless Congress reaches a funding agreement, nearly $6 billion for federally financed health clinics, which serve over 30 million people, most of them low-income, could lapse in early March.

A view of the brick exterior of Bethesda Pediatrics on a bright day.

Those health centers have each seen revenue losses of at least $500,000 because of the Medicaid unwinding, according to Amy Simmons Farber, a spokeswoman for the health center association.

By the end of December, Family Health Centers, a network of clinics in Louisville, Ky., had lost more than 2,000 Medicaid patients since the policy change took effect in April, an almost 6 percent decline, said Melissa Mather, a spokeswoman for the clinic. For every percent decline in Medicaid patient visits, she said, the clinic experiences a revenue decline of $175,000 to $200,000.

Bethesda is now engaged in a “month-to-month game of survival,” said Amber Greene, Bethesda’s operations manager, who also works as a nurse. Standing in a supply closet to make her point, she gestured to a modest stash of Tylenol, Motrin and thermometers, which the church next door had donated.

The clinic, with the vast majority of its patients on Medicaid, needs roughly $115,000 each month to operate its medical and dental clinics, but still runs a monthly deficit of around $10,000. Sometimes the costs it eats are small, such as the fee for the shot Dr. Price administered to the mother who could not pay. But they add up, forcing the clinic to get creative to preserve funds. A local pharmacy offers substantially discounted antibiotics, and the clinic cut the costs of its virus tests by conducting them in-house.

Texas health officials have defended the unwinding as a natural reversion to Medicaid’s intended shape and size. Conservative health policy experts have also argued that shrinking the rolls is important to sustaining the program financially.

“The reality is that many health professionals cannot sustainably see Medicaid patients because the program reimburses so little, and the claims process is so excruciating, many providers end up taking losses to the point it threatens closure,” said Tanner Aliff, a health policy expert at the conservative Texas Public Policy Foundation.

Roughly a third to a half of the those on track to lose Medicaid could remain uninsured, according to Dr. Benjamin D. Sommers, a health economist at Harvard and former Biden administration official who has researched state data on Medicaid losses. Some clinics will continue to provide care for some of those people and absorb the costs. But there is a limit to how much they can sustain financially.

The costs have been passed on to insurers and patients of all types, increasing out-of-pocket payments for everything from emergency room visits to hospital stays to routine doctor appointments, according to data from Epic Research .

Texas has been the nation’s chief Medicaid dismantler. More than two million people in the state have been removed from the program, according to recent state data — the highest total nationwide. Around two-thirds of those removed have been children.

Around half of Bethesda’s appointment slots were empty this past week, Dr. Price said on Thursday, prompting a new phase of desperation in which clinic staff members have discussed how to preserve care for families they have long had relationships with.

“This is going to be a long-term process of convincing those who are not going to have insurance that it’s still worth coming in,” he said.

Across the state at Hendrick Health, a nonprofit hospital in Abilene, Texas, Medicaid revenue was down roughly 30 percent late last year compared to the same time the year before, according to Jeremy Walker, the hospital’s chief financial officer. The slide has hurt the resources of the hospital, he said, noting that it needs Medicaid patients to preserve its federally sponsored drug discount program.

“The populations they have to deal with are often very challenging, chronically ill and expensive. And the reimbursement is not very good. That’s always the challenge,” said Timothy McBride, a health economist at Washington University in St. Louis.

The coverage losses are happening at an especially precarious time. Winter viruses are still circulating. Children are increasingly in need of behavioral health services , childhood vaccines and routine care for conditions such as diabetes and asthma, which commonly afflict low-income Americans.

Jessica Tucker, a single mother, broke into tears after receiving a $90 bill for her 3-year-old son Raylan’s primary care visit and tetanus vaccine at Bethesda, pleading with her mother by phone for help paying it. That morning, she had been informed that the toddler had been denied Medicaid coverage.

“I didn’t know what to do,” Ms. Tucker, who earns $10 per hour in a part-time job as a customer service associate, said, recounting the ordeal from her home in Gun Barrel City. She recently received a bill of almost $8,000 for an emergency room visit Raylan had after losing Medicaid, she said. His diagnosis: strep throat.

Bethesda has held onto the medical bills of some patients with the expectation that their Medicaid coverage will be restored. But longer gaps between payments can further strain operations. Bethesda recently lost a behavioral health counselor and is searching for grant funds to cover a new one.

To stay financially afloat, the clinic works to see as many patients as possible. Dr. Price can handle about 25 patients in a day, but often they require more attention than the allotted appointment time to address the complexity of some children’s health conditions. He frequently spends the extra time with them despite not receiving more in Medicaid reimbursement.

Bethesda’s status as a nonprofit means that it relies heavily on private donors. A church next door that has long sponsored Dr. Price and the clinic recently decided to give up its food pantry and some of its administrative staff to preserve funding for the medical operations, he said.

Dr. Price added that some potential donors to Bethesda were religious conservatives who might otherwise have hostile views of Medicaid. When he speaks at fund-raisers, he sometimes meets skepticism about the program.

“If they’ve lived their whole lives affluent, they don’t understand the need for clinics, for Medicaid,” Dr. Price said.

The complicated attitudes toward Medicaid show up regularly at the clinic. Many parents of patients said that they felt judged or shamed by family members who see government-subsidized health benefits as unseemly.

Destiny Sage, a Medicaid recipient from rural Chandler, Texas, said her mother did not believe in government benefits.

“She didn’t want me getting Medicaid,” said Ms. Sage, who brought her stepson, a Medicaid recipient, for an A.D.H.D. checkup with Dr. Price. A different son had just lost Medicaid coverage, making her nervous about unaffordable medical bills after she spent the little money she had on a water heater.

In many places, Medicaid providers are among the few health-care facilities that will accept any patient who walks through the door. A hospital near Bethesda warns with a large sign in all capital letters that it takes only patients who are commercially insured.

People with Medicaid said that the coverage was helping to keep their lives from catastrophe, and feared what would happen if it is taken away.

Cherokee Winchell, an elementary school lunch lady, spoke with Dr. Price about her 7-year-old son needing his tonsils removed, and about how his A.D.H.D. medication needed reconfiguring. Medicaid was holding her family together, she said, including by covering her son’s weekly occupational therapy sessions. But she dreaded losing their coverage and further straining the family’s already precarious finances. She was struggling to buy groceries, relying on Hamburger Helper and Salisbury steak.

Jessica McElroy arrived at Bethesda on a recent morning with her 3-year-old son, who still has Medicaid coverage, anxious about a possible autism diagnosis. She beamed as she told Dr. Price that he had the social skills of an adult, shaking hands with people he meets and standing upright with his hand over his heart during renditions of the national anthem at football games. But he was struggling to communicate, she said. He recoiled at loud noises, including in movies.

Dr. Price reassured her. “The more brilliant ones are the harder ones to make spectrum diagnoses for because they stay a step ahead of us,” he said.

Still, Dr. Price and Ms. McElroy worried about the two trips to a Medicaid-accepting autism specialist she was referred to an hour’s drive away. She said she worried about losing his Medicaid coverage altogether.

Ms. McElroy said last week that the specialist told her to look for other options; there were no available Medicaid providers for an evaluation or a speech therapist.

She has settled for a different strategy to help her son, she said: speech therapy tutorials on YouTube.

Noah Weiland writes about health care for The Times. More about Noah Weiland

Desiree Rios is a photojournalist and a New York Times fellow , based in New York. More about Desiree Rios

Advertisement

Watch CBS News

Medicaid expansion increased emergency room visits, study finds

January 2, 2014 / 4:05 PM EST / AP

SALEM, Ore. -- A new study has found that people enrolled recently in Medicaid went to the emergency room 40 percent more frequently than others, often seeking help for conditions that could be treated less expensively in a doctor's office or an urgent care clinic.  

The findings help inform a long-running debate about the effect of expanding Medicaid and suggest that hospitals and health officials around the nation should be prepared for an increase in emergency room trips in the coming months.

The study is the third to arise from a limited expansion of Medicaid in Oregon five years ago. Demand exceeded the available funding, so the state used a lottery to randomly choose people for coverage from a waiting list. The lottery created two groups of similar people, one consisting of new Medicaid patients, the other a comparison group of people who weren't selected. It gave scientists a rare chance to evaluate the program in a randomized, controlled study -- the gold-standard for scientific research.    

"We've been able to eliminate some extreme views about the program," said Sarah Taubman of the National Bureau of Economic Research, the study's lead author. "In the absence of that evidence, there were some unduly pessimistic views and some unduly optimistic views" about the effects of Medicaid.

Researchers used hospital records to look at ER use over 18 months for 25,000 people in the Portland area who entered the Medicaid lottery, some who were chosen for coverage and some who were not. Patients with Medicaid made, on average, 1.43 ER visits, compared with 1.02 for those who lost the lottery, an increase of 40 percent.

The study also found that 35 percent of people who weren't selected for Medicaid made an ER visit during the research period. For those who gained coverage, however, the number was 7 points higher at 42 percent.

Men were more likely than women to have additional ER visits, but there was no racial, age or other groups that saw a statistically significant decrease in ER usage among the people selected for Medicaid.

ER visits increased both during nights and weekends and during typical business hours, when ER alternatives would generally be open. The additional visits were exclusively outpatient, and many of the Medicaid patients were diagnosed with conditions that could have been treated in a primary-care office.

The study doesn't pinpoint a reason for the increased visits. In interviews, the authors said there's no data to know for sure but it's possible that patients are quicker to have their injuries and ailments checked out if they know they won't be stuck with a large hospital bill. Some patients may be visiting the ER on the advice of a primary-care physician.  

The authors caution against concluding that ER use rose because there wasn't enough access to primary care. Their earlier research found that Medicaid patients reported more visits to doctors' offices and use of preventive care.

Oregon's expanded Medicaid population was relatively similar to the group that's gaining coverage under the federal health law, but experiences elsewhere might differ, the researchers said. Oregon opened Medicaid to a tiny share of its uninsured population, reducing the amount of strain on the health care system's capacity. Portland's low-income population is also disproportionately white compared to most other U.S. metro areas.

Alissa Robbins, a spokeswoman for Oregon's Medicaid agency, said the state is aggressively working to reduce Medicaid costs - an effort that began after the period studied. The state has created incentives for doctors, hospitals and mental health providers, and some are targeting frequent ER users.

"Increasing coverage and seeing people use more medical care isn't necessarily a bad thing," said Dr. Renee Hsia, an associate professor of emergency medicine at University of California San Francisco and a health policy researcher who wasn't involved in the study but reviewed it for Science. "The outcome that we desire is not that we don't have people going to see their doctors anymore. The outcome is that we have people who feel protected from (financial problems and) seeking care when they feel they need it."

More from CBS News

Estimates of Emergency Department Visits in the United States, 2016-2021

The National Hospital Ambulatory Medical Care Survey (NHAMCS), conducted by the National Center for Health Statistics (NCHS), collects annual data on visits to emergency departments to describe patterns of utilization and provision of ambulatory care delivery in the United States. Data are collected from nonfederal, general, and short-stay hospitals from all 50 U.S. states and the District of Columbia, and are used to develop nationally representative estimates.

This visualization depicts both counts and rates of emergency department visits from 2016-2021 for the 10 leading primary diagnoses and reasons for visit, stratified by selected patient and hospital characteristics. Rankings for the 10 leading categories were identified using weighted data from 2021 and were then assessed in prior years; however, rankings were relatively consistent over the evaluated years. See tables in the Definitions section below the visualization for changes in leading primary diagnoses and reasons for visit from 2016-2021. Estimates in this visualization highlight and expand on information provided in the annual NHAMCS web tables , which can be used to assess how these categories and rankings changed over the evaluated years.

Use the tabs at the bottom of the visualization to select between “Primary Diagnosis” and “Reason for Visit”.  Use the drop-down menus at the top of the visualization to select the estimate type, the estimate category, and the group breakdown of interest.

Access Dataset on Data.CDC.gov (Export to CSV, JSON, XLS, XML) [?]

Definitions

Based on International Classification of Diseases, 10th Revision, Clinical Modification (ICD–10–CM).  See Table 11 of the NHAMCS: 2020 Emergency Department Summary Tables for code ranges of diagnosis categories, available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2020-nhamcs-ed-web-tables-508.pdf .

SOURCE: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2016-2021

Based on the patient’s own words and coded according to: Schneider D, Appleton L, McLemore T. A reason for visit classification for ambulatory care. National Center for Health Statistics. See Appendix II of the 2020 NHAMCS public-use documentation for code ranges of reason categories, available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc20-ed-508.pdf .

Calculated by dividing the number of ED visits by estimates of the U.S. civilian noninstitutionalized population (obtained from the U.S. Census Bureau’s Population Division) for selected characteristics including age, sex, and race and ethnicity. Visit rates for MSA are based on estimates of the U.S. civilian noninstitutionalized population from the National Health Interview Survey, compiled according to the Office of Management and Budget definitions of core-based statistical areas. More information about MSA definitions is available from: https://www.census.gov/programs-surveys/metro-micro.html . Visit rates for patient’s expected source of payment are based on patient’s primary expected source of payment and proportional insurance data from the National Health Interview Survey.

During data collection, all sources of payment were collected. For patients with more than one source of payment, the hierarchy below was used (with Medicare counted first and self-pay and no charge counted last) to collapse payments into one mutually exclusive variable (expected source of payment). Visits that had a missing or unknown expected payment source were excluded (between 10-14% [weighted] from 2016-2021).

  • Medicare: Partial or full payment by Medicare plan includes payments made directly to the hospital as well as payments reimbursed to the patient. Charges covered under a Medicare-sponsored prepaid plan are included.
  • Medicaid: Partial or full payment by Medicaid plan includes payments made directly to the hospital or reimbursed to the patient. Charges covered under a Medicaid-sponsored prepaid plan (HMO) or “managed Medicaid” are included.
  • Private: Partial or full payment by a private insurer (such as BlueCross BlueShield), either directly to the hospital or reimbursed to the patient. Charges covered under a private insurance-sponsored prepaid plan are included.
  • Uninsured: Includes self-pay and no charge or charity. Self-pay are charges paid by the patient or patient’s family that will not be reimbursed by a third party. Self-pay includes visits for which the patient is expected to be responsible for most of the bill, even if the patient never actually pays it. This does not include copayments or deductibles. No charge or charity are visits for which no fee is charged (such as charity, special research, or teaching).
  • Other: Includes Worker’s Compensation and other sources of payment not covered by the above categories, such as TRICARE, state and local governments, private charitable organizations, and other liability insurance (such as automobile collision policy coverage).

Race and Hispanic ethnicity were collected separately and converted into a single combined variable that includes non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic other people. Non-Hispanic other people includes Asian, Native Hawaiian or Other Pacific Islander, and American Indian or Alaska Native people, and people with two or more races. Missing values for race and ethnicity were imputed as described in the 2019 NHAMCS public-use documentation, available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc19-ed-508.pdf .

Please send comments or questions to [email protected] .

Data Source

National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2016-2021

Suggested Citation

National Center for Health Statistics. Emergency Department Visits in the United States, 2016-2021. Generated interactively: from https://www.cdc.gov/nchs/dhcs/ed-visits/index.htm

Exit Notification / Disclaimer Policy

  • The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
  • Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
  • You will be subject to the destination website's privacy policy when you follow the link.
  • CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

Suggestions or feedback?

MIT News | Massachusetts Institute of Technology

  • Machine learning
  • Social justice
  • Black holes
  • Classes and programs

Departments

  • Aeronautics and Astronautics
  • Brain and Cognitive Sciences
  • Architecture
  • Political Science
  • Mechanical Engineering

Centers, Labs, & Programs

  • Abdul Latif Jameel Poverty Action Lab (J-PAL)
  • Picower Institute for Learning and Memory
  • Lincoln Laboratory
  • School of Architecture + Planning
  • School of Engineering
  • School of Humanities, Arts, and Social Sciences
  • Sloan School of Management
  • School of Science
  • MIT Schwarzman College of Computing

Study: With Medicaid, ER visits remain high for two years

Press contact :, media download.

er visits with medicaid

*Terms of Use:

Images for download on the MIT News office website are made available to non-commercial entities, press and the general public under a Creative Commons Attribution Non-Commercial No Derivatives license . You may not alter the images provided, other than to crop them to size. A credit line must be used when reproducing images; if one is not provided below, credit the images to "MIT."

er visits with medicaid

Previous image Next image

People enrolled in Medicaid significantly increase their emergency room visits for at least two years after they first sign up, according to a new study co-authored by an MIT economist. The finding will likely surprise those health care experts who have projected that people would make fewer ER visits after acquiring health insurance.

The finding is the latest one from a unique randomized, controlled trial of Oregon’s health care system. An earlier finding from the research project showed that ER visits initially increased after people enrolled in Medicaid. In response, some health care analysts predicted the number of ER visits would still attenuate with time, as Medicaid users became more fully immersed in the health care system and used primary care physicians more often.

Instead, the new study shows that ER visits, which increase by about 65 percent for Medicaid users in their first six months in the program, hold steady at roughly that rate for two solid years, not just the initial time period.

“Contrary to the conjecture that Medicaid would get people to [move] out of the emergency room and to the primary care physician, we’re seeing a persistent increase in emergency room use,” says Amy Finkelstein, the John and Jennie S. MacDonald Professor of Economics at MIT, who is a co-author of a new paper on the findings.

That’s not all the researchers found this time around, either: They estimate that having Medicaid leads to a 13.2 percentage point increase in the probability of someone making both an ER visit and a regular primary care visit, which is larger than the increase that would be expected if ER visits and primary care visits were being made independently of each other. This suggests increased use of these two forms of health care is linked.

“If anything, it’s looking like Medicaid makes these two types of care more complementary, not more substitutable,” Finkelstein says.

The finding has significant implications for understanding the effects of Medicaid coverage on the previously uninsured, during a time period when states have had the option of using federal funds to expand their Medicaid programs.

The paper, “The Effect of Medicaid on ED Use — Further Evidence from Oregon’s Experiment,” is being published today in the New England Journal of Medicine. (The ED in the title refers to “Emergency Department.”)

In addition to Finkelstein, the co-authors of the paper are Katherine Baicker, a professor at Harvard University’s T.H. Chan School of Public Health; Heidi L. Allen, an assistant professor at the Columbia University School of Social Work; Sarah L. Taubman, an affiliate assistant professor at the University of Washington; and Bill J. Wright of the Center for Outcomes Research and Education, at Providence Health and Services, a nonprofit healthcare provider in Oregon.

Lottery winners — and losers

To construct their randomized, controlled trial, the first of its kind pertaining to Medicaid, the researchers have capitalized on a unique policy Oregon implemented in 2008. State officials at the time had Medicaid funds for about 10,000 additional adults and conducted a lottery for those places, receiving about 90,000 applications.

That lottery system let the researchers compare one group of Oregonians (those who had obtained Medicaid coverage via the lottery) to another otherwise similar group (namely, those who entered the Medicaid lottery but did not win).

“It’s the only randomized evaluation of covering the low-income uninsured in the United States,” Finkelstein notes.

Medicaid is the federal program that helps insure mostly low-income citizens, although eligibility requirements can vary by state. In Oregon, adults and children are usually eligible for Medicaid when their household income is no more than 133 percent of the federal poverty level established by the U.S. Department of Health and Human Services — which in 2016 was $11,880 for a single person and $24,300 for a family of four, in the 48 contiguous states.

Baicker and Finkelstein, who lead the research project, have published multiple papers on the subject over the last five years. In a 2011 paper published in the Quarterly Journal of Economics, they showed that Medicaid coverage increases doctor visits, prescription drug use, and hospital admissions, while reducing out-of-pocket expenses and unpaid medical debt. It also increases self-reported good health. In a 2013 paper published in the New England Journal of Medicine, they demonstrated that Medicaid coverage reduces the incidence of depression but does not change some physical health measures such as blood pressure.

Their previous finding on the initial use of ER services was published in 2014, in the journal Science.

Those published results have sometimes led pundits and political figures to make blanket judgments about the value of Medicaid as a whole. But Finkelstein says she prefers not to leap too far from the empirical results, which themselves give policymakers new data about health care usage rates.

“One always should exercise caution in extrapolating,” she says. Still, she notes, the findings on ER use apply “across the board, across types of people, types of care. … If we’re trying to make educated guesses, this would move my priors [prior assumptions] strongly toward [expecting] increases rather than decreases in emergency room use.”

  • J-PAL North America

The Oregon papers have had a wide impact in the health care policymaking community — and an institutional impact at MIT. Spurred on by the Oregon study and its reception, in 2013 Finkelstein co-founded the group J-PAL North America, along with Harvard economist Lawrence Katz, to encourage randomized evaluations of social policies designed to reduce poverty in the U.S.

The group is a branch of MIT’s Abdul Latif Jameel Poverty Action Lab, a network of 136 professors at over 40 universities that was founded in 2003 to support randomized trials in development economics globally.

J-PAL North America’s research program has three initiatives. The Health Care Delivery Initiative uses randomized trials to study ways of making medical care more efficient. The General Research Initiative applies randomized evaluations to a wide range of topics, including education, jobs, criminal justice reform, and energy issues. The State and Local Innovation Initiative is intended to examine the effectiveness of policy programs once they are implemented.

It is not always possible to conduct randomized trials on social issues in every state-level setting, but they can have laboratory-like qualities when they are possible to conduct. Enrollment lotteries for social programs are one mechanism that potentially allows such trials to occur.

“A randomized, controlled evaluation gives you the ability to be surprised,” Finkelstein concludes.

Share this news article on:

Press mentions, the washington post.

Washington Post reporter Carolyn Johnson writes that a study by Prof. Amy Finkelstein finds that expanding Medicaid access increases emergency room visits. “People who gained Medicaid visited the emergency room about 65 percent more often than individuals who did not gain Medicaid in the first six months -- and the trend continued out to two years.”

Previous item Next item

Related Links

  • Paper: "Effect of Medicaid Coverage on ED Use — Further Evidence from Oregon’s Experiment."
  • Amy Finkelstein
  • Department of Economics

Related Topics

  • Health care
  • Social sciences

Related Articles

Amy Finkelstein

3 Questions: Amy Finkelstein on testing health care systems

er visits with medicaid

Study: Having Medicaid increases emergency room visits

er visits with medicaid

How Medicaid affects adult health

Amy Finkelstein

Amy Finkelstein wins John Bates Clark Medal

er visits with medicaid

Medicaid’s impact, finally measured

More mit news.

Decorative image of a laptop floating among abstract, grid-like charts and objects.

Using generative AI to improve software testing

Read full story →

One person stands behind a lectern with four seated panelists to her left. Above them, a screen displays "Sustainability connect 2024." Boston’s skyline fills the windows behind them.

At Sustainability Connect 2024, a look at how MIT is decarbonizing its campus

Picnic tables in MIT's Hockfield Court underneath trees with yellow leaves

School of Science announces 2024 Infinite Expansion Awards

Illustration of five diverse people wearing headphones or earphones. A curvy staff line with treble chef and notes are in background

Exposure to different kinds of music influences how the brain interprets rhythm

Close-up of large magnet inside a cryostat container

Tests show high-temperature superconducting magnets are ready for fusion

Rendering shows the Perseverance on the rocky brown surface of Mars. The Perseverance resembles a go-cart and has 6 wheels and an arm extending that houses the drill. The top of the Perseverance has a long neck and a camera on top.

Study determines the original orientations of rocks drilled on Mars

  • More news on MIT News homepage →

Massachusetts Institute of Technology 77 Massachusetts Avenue, Cambridge, MA, USA

  • Map (opens in new window)
  • Events (opens in new window)
  • People (opens in new window)
  • Careers (opens in new window)
  • Accessibility
  • Social Media Hub
  • MIT on Facebook
  • MIT on YouTube
  • MIT on Instagram

Is my child going to lose Medicaid? What families need to do now to avoid being dropped

er visits with medicaid

For three years after the pandemic began, people who have Medicaid health coverage were automatically reenrolled, and didn't have to verify annually that they qualified for this benefit.

That continuous Medicaid coverage ended on March 31. In Texas, the end to continuous coverage means that the state has to reverify that 2.7 million women and children still qualify for Medicaid to keep them enrolled.

The U.S. Department of Health and Human Services predicts that as many as 15 million people nationwide could be disenrolled in Medicaid during this process, including 6.8 million who still qualify for Medicaid.

Why is the end of continuous Medicaid coverage important?

Staff at local clinics worry that families might not be aware of the changes, said Lucy Sumner, vice president of revenue cycle at Austin Regional Clinic. These families are working to make ends meet, caring for children, lacking time to work through red tape on the phone or on the computer, or might have moved.

Clinics worry that if families don't maintain their Medicaid status, they might put off preventative care, which many kids fell behind on during the pandemic. Families also might seek nonemergency care at the emergency room rather than go to a primary doctor because they can't afford health care.

Who can get Medicaid?

Medicaid qualifications are based on family size and monthly income. For example:

  • A family of four making less than $3,083 a month qualifies for Medicaid for their children.
  • Some parents in extreme poverty can get Medicaid if a family of four, with two parents, earns less than $285 monthly.
  • Families with children with disabilities can qualify if they cannot afford health care premiums.
  • Pregnant women with a family of four making less than $4,579 a month can receive Medicaid during pregnancy and up to two months after the baby's birth. There are bills in this Texas Legislature this session to extend it to a year.

Learn more: Texans can be at risk for Medicare fraud. What you need to know to protect yourself.

What do I need to do?

Starting this month, you have to verify your income and make sure Medicaid has your current contact information to stay enrolled.

Create or log into your account at YourTexasBenefits.com or the Your Texas Benefits app. In your account, ensure your information is correct, including address, phone number, email, family size, age of children and income.

You can call 211 and press option 2 or go to your local Medicaid enrollment office. To find a Texas Health and Human Services office or a community partner, visit yourtexasbenefits.com/Screener/FindanOffice .

Then watch your mail or email. Yellow envelopes with red lettering that say "Action Required" are being mailed to people with a renewal form. If you have a YourTexasBenefits.com account, that form will come electronically.

Once you have the form, you need to return it by the due date, in some cases in 30 days. You need documentation to verify your income and identity. You can submit the application, renewal form and information by:

  • Mailing to Texas Health & Human Services, P.O. Box 149024, Austin, TX 78714-9024
  • Faxing to 877-447-2839
  • Calling 211 and choosing option 2 after picking a language.
  • Visiting a local office or a community partner.

What happens if I don't turn in my renewal packet or request for information?

Benefits will be terminated. You will receive a notice stating that you will no longer receive health care coverage. You will have 90 days to respond, and the state will process your information without requiring you to submit a new application. After 90 days, you have to fill out a new application.

What is the timing of the reenrollment?

Texas began sending out letters about reenrollment in January.

The actual re-verification process continues throughout the year. The first renewal applications went out April 8. Batches of applications will be sent through September. The state is prioritizing reenrollment of people most likely to no longer qualify first. These are:

  • People who have turned 19 during this three-year period.
  • Previously pregnant women who had their babies and are past the postpartum period of coverage.
  • People known to have had a change in family income.

Then the state will start working through the remaining 2.7 million women and children who receive Medicaid.

The re-verification process is not likely to affect Medicaid programs for seniors or people with disabilities.

Access to care: Central Health's demographics report: a story of poverty and health access in Travis County

What happens if my family no longer qualifies for Medicaid?

If children qualify for the Children's Health Insurance Program, or CHIP, which allows for a higher family income, the state says it would enroll kids in CHIP. Families who still don't qualify will be given information about other resources, including the insurance marketplace on healthcare.gov.

Families also can go for care to federally qualified health clinics such as CommUnityCare, People's Community Clinic and Lone Star Circle of Care, which offer sliding-scale fees based on income.

If my child loses Medicaid, can we still get treatment?

Losing your health insurance doesn't mean you do not have care, said Lone Star Circle of Care’s Chief Operations Officer Lindsey Tippit. For emergencies, safety-net hospitals will treat patients regardless of their health insurance status.

"If you go to our hospital, our ER, we're going to make sure we take care of you no matter what," said Geronimo Rodriguez, chief advocacy officer at Ascension Texas, which includes Dell Children's Medical Center and Dell Seton Medical Center, the safety-net hospitals for children and adults in Travis County.

If a child who should qualify for Medicaid and doesn't have it arrives at the hospital, staff at Dell Children's will direct parents on how to enroll. Until they are enrolled, families might have to pay out-of-pocket for care, though Dell Children's and Ascension Texas have charity care funding.

If families are de-enrolled in Medicaid, they can go to doctors' offices that are not federally qualified health clinics, but pay out of pocket for the visits until they can get reenrolled. ARC's Sumner expects this will have a "massive" impact on patients, and "there's going to be a lot of unanticipated bills."

Does this affect other benefits such as SNAP, TANF and CHIP?

No. Those federal programs are not affected by the end of continuous Medicaid coverage.

How else is the state trying to reach people?

Texas Health and Human Services has been using social media posts, handing out flyers in community settings and sending Medicaid participants emails and texts to alert them of the changes. It also has an FAQ online to help answer questions.

What are clinics and hospitals doing to help people keep their benefits?

Clinics and hospitals across Central Texas are working to identify and reenroll their Medicaid patients.

At Dell Children's clinics and hospitals, staff have resource cards to help families. Austin Regional Clinic mailed 30,000 letters to patients on Medicaid about the reenrollment process. At Lone Star Circle of Care, where 45% of its 97,000 patients are on Medicaid, the patient services team is ready to help patients stay enrolled.

"We're trying to make this as smooth as possible," Tippit said. "Families don't have to navigate this alone."

Study: Most Seniors’ ER Visits Could Be Avoided

By Phil Galewitz October 5, 2012

Republish This Story

Nearly 60 percent of Medicare beneficiary visits to emergency rooms and 25 percent of their hospital admissions were “potentially preventable”–  had patients received better care at home or in outpatient settings —  according to results of a study released Friday by a congressional advisory board.

er visits with medicaid

The commission’s preliminary study, released at their monthly meeting, found the most common diagnosis for preventable ER visits was upper respiratory infections. The most common diagnosis for preventable hospital admissions was congestive heart failure.

The potentially preventable admissions or ER visits do not indicate the hospital acted inappropriately. Instead, they are a measure of a community’s outpatient care system that includes private physician offices, community health centers and urgent care centers, study co-author Nancy Ray, a MedPAC principal policy analyst, told commissioners. Ray said not every preventable ER visit or admission can be avoided. The study showed wide variation of these rates across the country and within cities.

Patients could avoid preventable ER visits by having health conditions treated by family doctors or urgent care centers or by making sure to take all their medicine. Hospital admissions could be prevented if conditions such as asthma, diabetes or heart failure were better monitored by patients and their doctors, commission staff said.

The study analyzed health services provided to 5 percent of all traditional Medicare program beneficiaries from 2006 to 2008.  It also looked at care provided to all Medicare beneficiaries in six markets: Boston, Phoenix, Miami, Minneapolis, Greenville, S.C., and Orange County, Calif. MedPAC officials said it would release marketplace details when the report is completed in a few months.

The study found hospitals that had lower occupancy rates had higher rates of preventable ER visits and admissions.  Medicare beneficiaries who also receive Medicaid— a category known as “dual eligibles” — also had higher rates.

Researchers have been looking at reducing preventable ER visits and hospital admissions for years, though this is one of the first large analyses of Medicare patients. Hospitals in 2006 spent $30.8 billion on 4.4 million hospital admissions that might have been avoidable, according to a report by the federal Agency for Healthcare Research and Quality.  A 2006 Rutgers University study found 47 percent of ER visits in New Jersey were potentially avoidable.

Copy And Paste To Republish This Story

Nearly 60 percent of Medicare beneficiary visits to emergency rooms and 25 percent of their hospital admissions were “potentially preventable”–  had patients received better care at home or in outpatient settings —  according to results of a study released Friday by a congressional advisory board.

“These are spectacular rates,” said Scott Armstrong, a member of the Medicare Payment Advisory Commission and CEO of Group Health Cooperative, a Seattle-based health plan.

The commission’s preliminary study, released at their monthly meeting, found the most common diagnosis for preventable ER visits was upper respiratory infections. The most common diagnosis for preventable hospital admissions was congestive heart failure.

The potentially preventable admissions or ER visits do not indicate the hospital acted inappropriately. Instead, they are a measure of a community’s outpatient care system that includes private physician offices, community health centers and urgent care centers, study co-author Nancy Ray, a MedPAC principal policy analyst, told commissioners. Ray said not every preventable ER visit or admission can be avoided. The study showed wide variation of these rates across the country and within cities.

The study found hospitals that had lower occupancy rates had higher rates of preventable ER visits and admissions.  Medicare beneficiaries who also receive Medicaid— a category known as “dual eligibles” — also had higher rates.

We encourage organizations to republish our content, free of charge. Here’s what we ask:

You must credit us as the original publisher, with a hyperlink to our kffhealthnews.org site. If possible, please include the original author(s) and KFF Health News” in the byline. Please preserve the hyperlinks in the story.

It’s important to note, not everything on kffhealthnews.org is available for republishing. If a story is labeled “All Rights Reserved,” we cannot grant permission to republish that item.

Have questions? Let us know at KHNHelp@kff.org

More From KFF Health News

A stethoscope and voting pin rests on top of an American flag.

America Worries About Health Costs — And Voters Want to Hear From Biden and Republicans

Two female health care providers stand side by side reviewing notes.

California Pushes to Expand the Universe of Abortion Care Providers

A photograph of Rohit Chopra during the senate hearing. He holds his chin in his left hand in a contemplative position.

With Medical Debt Burdening Millions, a Financial Regulator Steps In to Help

er visits with medicaid

Journalists Examine Medicaid Unwinding, Farmworkers’ Mental Health, and the Big Opioid Payback

Thank you for your interest in supporting Kaiser Health News (KHN), the nation’s leading nonprofit newsroom focused on health and health policy. We distribute our journalism for free and without advertising through media partners of all sizes and in communities large and small. We appreciate all forms of engagement from our readers and listeners, and welcome your support.

KHN is an editorially independent program of KFF (Kaiser Family Foundation). You can support KHN by making a contribution to KFF, a non-profit charitable organization that is not associated with Kaiser Permanente.

Click the button below to go to KFF’s donation page which will provide more information and FAQs. Thank you!

Emergency Medicaid - Health First Colorado

  • Find a Doctor
  • Benefits & Services
  • News & Resources
  • Log in to PEAK

Emergency Medicaid Services (EMS) Overview

Who qualifies for ems.

  • Deferred Action for Childhood Arrivals (DACA) recipients
  • People without legal immigration status.
  • Non-immigrant visa holders such as tourists and students
  • People with Temporary Protected Status
  • Children and anyone who is pregnant may qualify for full Medicaid even if they haven’t been in the U.S. lawfully for at least five years.

Covered EMS Benefits and Services

How long does coverage last, how to apply, cover all coloradans: expanded coverage for pregnant people and children, additional resources, frequently asked questions:.

  • Health First Colorado Card
  • Health First Colorado Provider Search Tool
  • Application Resources
  • Reproductive and Maternal Health Programs Resources
  • EMS Family Planning Expansion Updates

For more information contact

Emergency Services

Covered benefits and services

  • Placing the member’s health in serious jeopardy
  • Serious impairment to bodily function,
  • Serious dysfunction of any bodily organ or part.
  • Labor and delivery (EMS does not cover prenatal or postnatal care)
  • Dialysis for End-Stage Renal Disease at a freestanding dialysis center
  • Life-threatening or severe symptoms, like chest pains or trouble breathing
  • Life-threatening or severe illnesses, like appendicitis
  • Life-threatening or severe accidents

Benefits and services that are NOT covered

  • Follow-up care after the medical emergency
  • Routine provider appointments
  • Prenatal or postnatal care (any pregnancy-related care you may get before or after a pregnancy)
  • Organ transplants
  • Care that is not for an emergency medical condition

Applying for EMS coverage

  • at the hospital when you get emergency treatment
  • after you leave the hospital
  • for any emergency care you got in the past three months

Cost of services

Get help during a medical emergency.

Reproductive Health Services

  • Oral birth control pill
  • Vaginal ring
  • Birth control shot
  • Birth control patch
  • Long-acting reversible contraception (LARC) devices such as an IUD or the implant. This includes coverage of the device and insertion, monitoring and removal.
  • Sterilization services such as tubal ligations and vasectomies.
  • Basic fertility assessments
  • Contraceptive counseling services to find out what method works best for you.
  • Diagnosis, treatment, prevention and follow up visits for sexually transmitted infections, lower genital tract and genital skin infections and urinary tract infections.
  • Cervical cancer screening and prevention
  • Related evaluations or preventative services such as tobacco cessation services or depression screenings

Applying for EMS coverage of family planning and family planning-related services

The Emergency Medicaid Services (EMS) benefit covers family planning , family planning-related, and services necessary to treat an emergency medical condition for people who qualify. EMS is a limited benefit that does not cover all medical services. It is also known as “Emergency Medical Services” or Emergency Medicaid and Reproductive Health Care Services (EMS/RHCS).

To qualify for EMS, you must meet all the requirements for Health First Colorado (Colorado’s Medicaid program) except for immigration or citizenship status requirements.

People who may qualify for EMS include, but are not limited to:

Please apply to see if you qualify — even if you are unsure if you qualify or about your immigration status. You do not need a Social Security number to qualify for EMS.

If you qualify for EMS and family planning services, we will send you a letter confirming your coverage. EMS members have coverage for 12 months until it’s time for renewal or there is a qualifying life event that changes your eligibility.

If you don’t qualify, but you have questions or think you should qualify for EMS, you can call your county’s Department of Human Services . This phone number will be listed on the bottom of the letter received. You can also get help applying at your local application assistance site .

EMS is a limited benefit plan. EMS only covers family planning, family planning-related, and services necessary to treat an emergency medical condition. You will not have full Health First Colorado coverage.

EMS members are covered for family planning and emergency services necessary to treat an emergency medical condition for 12 months unless you have certain life changes that changes eligibility. After 12 months, you will need to complete the renewal process to determine if you still qualify for health coverage.

Online: Go to CO.gov/PEAK and create an account to apply for public benefits, including EMS.

Phone: Call 800-221-3943 (State Relay: 711). Phone applications are available Monday through Friday from 8 a.m. to 4 p.m.

Mail: Download and print a paper application . (Available in English and Spanish).

In person: Apply in person at your county’s Department of Human Services or a local application assistance site . You do not need a Social Security number to apply. Go to this list of what you need to apply .

Confidentiality Notice: Information you provide on your application is confidential and cannot be shared with U.S. Citizenship and Immigration Services. Colorado law protects your personal information when applying for or enrolling in most public benefits. Your information may only be shared with some federal agencies if there is an audit from the Center for Medicare and Medicaid Services and the Office of the Inspector General. If shared, the information does not impact your immigration status and can’t be used in a public charge decision.

Coming in 2025: Expanded health coverage for pregnant people and children, known as Cover All Coloradans , will expand Health First Colorado and CHP+ benefits to children and people who are pregnant regardless of their immigration or citizenship status. Pregnant people will be covered for 12 months following the end of a pregnancy, and children will be covered until they turn 18. Learn more about the new Cover All Coloradans benefits .

Current members can call the Health First Colorado Member Contact Center: 800-221-3943 (State Relay: 711)

Provider information can be found on our Maternal and Reproductive Health Resources page or through the Gainwell Provider Portal .

The Emergency Medicaid Services (EMS) benefit covers family planning, family planning-related and services necessary to treat an emergency medical condition for people who qualify. To qualify for EMS, you must meet all requirements for Health First Colorado (Colorado’s Medicaid program) except for immigration or citizenship status requirements. It is also known as “Emergency Medical Services” or Emergency Medicaid and Reproductive Health Care Services (EMS/RHCS).

EMS includes emergency transportation and services necessary to treat an emergency medical condition — including but not limited to, laboratory, X-ray and other medical tests when ordered by a provider.

EMS covers services that, without immediate medical attention, could reasonably be expected to result in:

These services are also covered:

This list is not complete. If this is an emergency, please call 911 or go to the nearest emergency department.

Members do not need a provider’s note saying that the services provided were for an emergency. The provider will give this information to Health First Colorado.

EMS does not cover the following:

You do not need a Social Security number to get EMS.

You can apply for EMS

If you’re pregnant and need health coverage for future labor and delivery services, you can apply before, during, or after labor and delivery. People at the hospital can help you apply for EMS coverage.

There is no cost if the providers say you are having a medical emergency.

If you think you are having a medical emergency call 911 or go to the nearest emergency room.

Under federal law, all hospitals must provide emergency medical care to anyone having a medical emergency, even if they can’t pay for it, and even if they are not a U.S. citizen.

The Emergency Medicaid Services (EMS) includes Reproductive Health Care Services (RHCS) coverage of family planning and family planning related services. This is in addition to coverage of services needed to treat an emergency medical condition, and you will not need to reapply for coverage of the different types of care. EMS is also known as “Emergency Medical Services” or Emergency Medicaid and Reproductive Health Care Services (EMS/RHCS).

EMS covers both family planning services, such as birth control, and family planning-related services, such as sexually transmitted infection testing or cervical cancer screening and prevention.

Family planning services include services intended to delay, prevent or plan for a pregnancy, including:

Family planning-related services include services provided in a family planning setting during or in follow-up to a family planning visit.

To learn more about covered services, please visit the Benefit and Services page.

You do not need a Social Security number to apply for and get EMS coverage. You do not need to reapply for coverage of emergency services. To qualify for EMS, you must meet all the requirements for Health First Colorado except for immigration or citizenship status requirements.

If you have received family planning services in the last 90 days, you might be able to get help paying the bill.

Apply today to see if you qualify.

Family planning and family planning-related services should be provided at no cost to the member.

The Health First Colorado website and public messaging are made possible through grants from the Colorado Health Foundation and Caring for Colorado Foundation .

Member Contact Center 1-800-221-3943 / State Relay: 711

  • Web Accessibility
  • Accessibility Statement
  • Nondiscrimination
  • Website Feedback

© 2024 State of Colorado

er visits with medicaid

Medicaid patients now have 12 months of postpartum coverage in Texas

Midwife Nikki Knowles holds Scarlett, 6, up to listen to Baby Ransom while on Jessica Gamboa’s chest after birth Tuesday, March 28, 2023, at their home in Forney.

Starting today, Medicaid patients in Texas have 12 months of postpartum coverage.

Texas lawmakers passed a postpartum extension, bringing coverage from two months to twelve months, at the end of the last legislative session. The state submitted the extension to the U.S. Centers for Medicare and Medicaid Services (CMS) in October, and CMS approved it in January.

“That’s going to be a huge win for the health of folks who are wanting to become pregnant and have successful and healthy pregnancies,” said Stephanie LeBleu, the Title X project director at Every Body Texas.

LeBleu said many people who work in reproductive health have “identified the need” for 12 months of coverage for a long time.

“It’s very encouraging that we have gotten to this place,” she said. “Having a legislature that was able to pass this in a bipartisan way speaks loudly to an interest in supporting maternal health in the state.”

According to the national policy organization KFF , 44 states have implemented the 12-month postpartum extension. Thirty-eight of those states have also expanded Medicaid coverage to low-income adults; Texas is one of 10 states that has not expanded coverage.

Advocates and researchers have said 12 months of insurance coverage will help lower rates of maternal mortality and morbidity – both of which Texas ranks poorly in.

According to data from the U.S. Centers for Disease Control and Prevention (CDC) , more than half of pregnancy-related deaths nationwide happen within a year of giving birth. Mental health conditions like postpartum depression and anxiety, bleeding and heart conditions are the top causes for maternal mortality in the United States.

About 84% of the pregnancy-related deaths between 2017 and 2019 were preventable, according to the CDC, and disproportionately affect Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander people.

Patient Cherish Sims sits on the couch while Krystal Brown, Certified Nurse Midwife, gets the examine bed ready.

Parkland Health launched a program in 2020 to address these issues and provide more support to postpartum patients. The extending Maternal Care After Pregnancy (eMCAP) program connects patients to nurses and home visits to support their health needs after delivery.

Courtney Johnson, an advanced practice provider with eMCAP, said the program ensures patients “don’t get lost in the system after delivery.”

“It’s decreased a lot of unnecessary ER visits because you’re having that follow-up care with these patients, especially so early on postpartum,” she said.

She’s seen the impact 12 months of coverage has had on her own patients, and thinks the extension is needed.

“Insurance covering it for 12 months is going to be a great thing, especially continuing that care that these patients need,” Johnson said.

The Medicaid postpartum extension is automatically included for people currently enrolled or people who will be enrolled and become pregnant in the future. Coverage will also go into effect for people who were enrolled in Medicaid when pregnant and are still within the 12-month coverage window.

To apply for Medicaid or other federal insurance programs, or to check insurance status, visit YourTexasBenefits.com or call 211.

Got a tip? Email Elena Rivera at  [email protected]

KERA News is made possible through the generosity of our members. If you find this reporting valuable, consider  making a tax-deductible gift today.  Thank you.

er visits with medicaid

USA TODAY

Is housing health care? State Medicaid programs increasingly say ‘yes’

S tates are plowing billions of dollars into a high-stakes health care experiment: using scarce public health insurance money to house the poorest and sickest Americans.

Homelessness jumped 12% in the U.S. last year, to an estimated 653,104 Americans, the highest level on record. At least 19 states are directing money from Medicaid – the state-federal health insurance program for low-income people – to address the crisis, according to the Centers for Medicare and Medicaid Services.

California is going the biggest, pumping $12 billion into a Medicaid initiative largely to help homeless patients find housing, pay for it and avoid eviction. Arizona is allocating $550 million in Medicaid funding primarily to cover six months of rent for homeless people. Oregon is spending more than $1 billion on services such as emergency rental assistance for patients facing homelessness.

Start the day smarter. Get all the news you need in your inbox each morning.

Even ruby-red Arkansas will dedicate nearly $100 million partly to house its neediest. Tennessee, West Virginia and Montana are in the pipeline.

The Biden administration is encouraging other states to jump in. It’s part of a broader White House strategy that encourages Medicaid directors to offer social services alongside traditional medical care, with the goal of making their residents healthier.

“A health care dollar can do more than just pay for a doctor visit or hospital stay,” Xavier Becerra, secretary of the U.S. Department of Health and Human Services, told KFF Health News. “Is there anyone who would deny that someone who is homeless is going to have a harder time also keeping their health up?”

It’s not just states experimenting with this approach. Sherry Glied , a New York University professor and former Obama administration official, pointed to at least 57 health systems and 917 hospitals around the country that have launched social service initiatives, with most focusing on housing.

Becerra acknowledged these initiatives are experimental. But he said the federal government can no longer ignore the rampant death and disease that is plaguing homeless people.

“We’re simply saying, ‘State, if you can prove to us that with this Medicaid dollar you will improve someone’s health or health outcome, then you have essentially served the purpose of the Medicaid program and you’re saving taxpayers more money,’” he said.

However, evidence supporting this argument is mixed. There’s little agreement that this strategy will provide a long-term fix for vulnerable patients’ health or housing.

For instance, in a trial by researchers at the University of California, San Francisco, homeless people in Santa Clara County, California, who were randomly assigned to receive long-term housing and services used the psychiatric emergency department 38% less than a control group over four years while increasing their use of routine mental health care. But participants were still hospitalized at high rates and continued to rely on the emergency room.

Still, states are forging ahead.

Arizona: Saving $4,300 per person

Arizona saw a 5% jump in homelessness in 2023. “Housing agencies are maxed out and we have enormous need to help stabilize people,” said Alex Demyan, assistant director of the state’s Medicaid agency.

A state-funded Medicaid initiative is providing 3,000 rent vouchers for people in southern Arizona who have a severe mental illness and are homeless or at risk of becoming homeless. That program slashed ER visits 45% and reduced hospital inpatient admissions 53% at the six-month mark after patients started receiving services, while increasing less costly preventive care 56% and saving $4,300 per member, per month, according to state data .

“We’ve seen such positive health outcomes and cost reductions as a result, so it made total sense to us to expand our work in that space,” Demyan said.

Now the state is adding a Medicaid program that will prioritize homeless people and those at risk of losing housing who also have a mental health condition and chronic illness. It will provide rent payments for up to six months and transitional housing, which can include shelters with intensive services.

'A sad situation': Homeless campers in Arizona prepare to leave as closure approaches

West Coast solutions

California is home to nearly 30% of the nation’s homeless population. The state launched its massive CalAIM initiative in 2022 to offer a wide variety of social services to a small sliver of the state’s roughly 15 million Medicaid enrollees . A large part of the resources is going to housing.

“If you’re saddled with a great deal of either physical or behavioral health conditions, whether it’s diabetes or HIV, high blood pressure or schizophrenia, without housing, it’s really hard to stabilize those conditions,” said Mark Ghaly , secretary of the California Health and Human Services Agency.

But he cautioned that Medicaid’s core focus must remain getting people healthy, even if they’re living outside. That is a monumental and expensive challenge because conditions like diabetes, heart disease and HIV require continuous treatment and often multiple medications.

“I do not think that health care is responsible for solving homelessness,” Ghaly said. “But if housing instability or lack of housing is one of the key drivers getting in the way of being healthy, then absolutely we need to pay attention to it.”

Health insurers that provide Medicaid coverage in California can choose whether to provide housing services, but Oregon is requiring Medicaid insurers to do so. The state is targeting patients at risk of becoming homeless. Participants will be eligible for six months of rent and other services when the program launches in November, said Dave Baden, deputy director of the Oregon Health Authority.

Mission creep

Not all health care leaders – or even homelessness experts – believe housing is the best use of Medicaid money, especially for a safety-net program that faces routine criticism for failing to provide health care to many enrollees.

State Medicaid programs often struggle to deliver basic medical services , such as childhood dental visits and breast cancer screenings. In California, the state spending the most on housing, children on Medicaid did not have timely access to care for mental health or substance use in 2022, according to a November audit .

“If you’re on Medicaid, you often have to wait months and months for a specialty visit, even if it’s a life-threatening concern, so I worry about what people won’t be able to get because of this,” said Margot Kushel , a leading homelessness researcher and doctor in San Francisco who primarily treats low-income patients.

Kushel said the danger is that most Medicaid housing assistance can be used only once or is time-limited.

“By the time folks get into housing, they’re already really, really sick,” she said. “What happens at the end of six months when rental assistance like free rent runs out?”

That’s why the Oregon program is “really trying to focus on people teetering on the brink,” deputy director Baden said. “If you’re already homeless, you really need longer, sustainable housing dollars to keep that person housed.”

Glied, the NYU professor, warned in a recent health policy analysis of mission creep in health care. She cautioned that social services could be a “dangerous distraction,” and argued that health programs should instead improve basic care and leave housing to organizations that specialize in it.

“Providing people with food or housing is pretty far removed from the core mission of health care,” she told KFF Health News.

Peter Lee, another former Obama administration official and the founding executive director of California’s Obamacare exchange, said health care providers should consider offering some housing and social services, but he too fears such initiatives may divert money from traditional medicine and prevent patients from getting care.

“In the past five to 10 years, there has been a lot of recognition that health is about much more than actual health care. Very true,” Lee said. “The question is how do you address those issues while health care itself is not doing too great.”

Still, states say they’re committed – even if their initiatives don’t pass a traditional cost-benefit analysis .

“The singular focus on a financial return on investment is not as clear as it was previously,” said Cindy Mann , a federal Medicaid director under Obama. “States are just seeing how little sense it makes to treat people and then release them back to the streets.”

This article was produced by KFF Health News , which publishes California Healthline , an editorially independent service of the California Health Care Foundation . KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – an independent source of health policy research, polling and journalism.

This article originally appeared on USA TODAY: Is housing health care? State Medicaid programs increasingly say ‘yes’

Homeless tents are set up along a retaining wall in Oklahoma City on Monday, Dec. 11, 2023.

State Medicaid program to stop paying for unneeded ER visits

Starting April 1, Medicaid will no longer pay for such visits, even when patients or parents have reason to believe they're having an emergency. Hospitals and doctors are pressing lawmakers to undo the policy.

Share story

Intent on cutting state budget health-care costs, Medicaid officials say the program will no longer pay for any medically unnecessary emergency-room visits, even when patients or parents have reason to believe they’re having an emergency.

The rules — arguably more drastic than an earlier proposal to limit Medicaid patients to three visits per year for nonemergency conditions — would block payment for ER visits for about 500 different conditions.

They would apply to all adults and children on Medicaid, with no exceptions, such as someone being brought in by ambulance or from a nursing home, or when patients have neurological symptoms or unstable vital signs.

Most Read Local Stories

  • 1 in 4 Washingtonians want state to secede, new survey shows
  • WA Legislature passes 3 initiatives covering taxes, schools and police chases
  • Seattle weather forecast: Chilly mornings and dry days ahead
  • Seattle police arrest three suspects in three separate homicides
  • Jaywalking debate pits safety concerns against unnecessary stops of homeless people

The new rules are to begin April 1, but a statewide group of emergency doctors, backed by the Washington State Medical Association and the Washington State Hospital Association, are pressing lawmakers to stop the plan, arguing it would shift costs to hospitals and ER doctors and deny care to people with real emergencies.

“The simple fact is that quality patient care does not happen when bureaucrats stand between the physician and patient to dictate what is considered an emergency and what is not,” Dr. Stephen Anderson, president of the Washington Chapter of the American College of Emergency Physicians, said in a statement released Tuesday. “It’s just not safe. And it’s just not right.”

The doctors and hospitals have proposed an alternative they say would reduce costs and protect quality care, but the state has dismissed it as having no specific plan or timetable for how it would be accomplished.

Dr. Jeff Thompson, chief medical officer for Washington’s Medicaid program, said the state is committed to paying for medically necessary care. But many times, he said, patients go to ERs when they would get better, and less expensive, care in a primary-care “medical home.”

“The ER cannot be the medical home of the 21st century,” he said. “We will not pay for diaper rash treated in the emergency room.”

Currently, there is “tremendous overuse and abuse” of emergency rooms, Thompson said — amounting to at least $21 million a year.

Some patients show up as many as 120 times a year for costs of $20,000 to $25,000, he said, but until now, most ER doctors and hospitals have done little to deter them because the state paid the bills.

“The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER,” Thompson said.

“They have not stepped up as leaders to actually be better stewards of care and safety and the public resources,” he said.

Under the new rules, ER services not paid by Medicaid wouldn’t be billed to the patient, leaving the doctor or hospital on the hook.

The skirmish between Medicaid and the doctors and hospitals is the latest in a long-running battle with origins in the state’s budget crisis.

Early last year, state Medicaid officials, eager to save as much as $76 million in the biennium, proposed a three-visit limit for any of about 700 conditions they said could be treated by a primary-care doctor.

The doctors and hospitals objected, noting the list contained not only obviously nonemergency conditions such as diaper rash or acne, but hypoglycemic coma, asthma attacks and chest pain — conditions that might indeed be emergencies.

In a lawsuit filed in Thurston County Superior Court last year, emergency physicians argued the state’s process was arbitrary and capricious.

In November, a judge ruled that the state had not followed a proper rule-making process, which would require public hearings.

The state pared the list, removing some of the most hotly contested conditions such as chest pain. But instead of going through the process to change the rule, officials sought guidance late last year from federal authorities, who provide part of the Medicaid funding.

According to Medicaid’s Thompson, they said the state could move to a “medically necessary” standard without having to change its rules or go through a hearing process.

Each side has accused the other of not collaborating to reach a mutually acceptable solution.

Thompson said he’s long offered to provide hospitals with a list of about 4,000 frequent ER users — primarily patients seeking narcotics. Out of about 1.2 million Medicaid patients in the state, these are the ones who use ERs far too much, running up total bills of about $7 million per year — a fair hunk of the $21 million a year Thompson said he needs to shrink his budget.

But until the state said it wouldn’t pay, hospitals weren’t interested in that list, said Thompson, who maintains that hospitals and ER doctors must do more to help patients find appropriate primary care.

Dr. Nathan Schlicher, an emergency physician in Tacoma and legislative chairman for the emergency-physicians state chapter, was in Olympia on Tuesday, urging lawmakers to stop the plan.

“The original plan was bad,” Schlicher said. “This plan is outrageous.”

For Medicaid patients, Schlicher said, the plan suggests that even before heading to the ER, they should know what their ultimate diagnosis will be.

“If we don’t know without an X-ray or CT scan, how can they know it?”

For doctors, the plan could place them in legal jeopardy, Schlicher said.

If they turn patients away, “it’s not good care and it doesn’t meet the legal standard,” he said. “I can’t tell any provider to commit medical malpractice, no matter how much the state wants us to do that.”

But if the doctors provide care for any of the conditions on the state’s list, such as an ear infection or a bladder infection, they would have to do it for free.

Schlicher said he and other doctors have offered about 200 conditions they agree are most often not emergencies, but want the state to allow exceptions for a patient’s condition — such as when their vital signs are unstable or they have neurological symptoms.

The doctors have offered what they call a physician-developed plan they say would reduce narcotic-seeking behavior, coordinate ER visits with primary-care access, spearhead a “generics first” effort, develop a statewide preferred-drug list, and institute a case-management system for frequent users.

Schlicher said if the state’s current plan is implemented, it would be the most restrictive Medicaid ER policy in the nation.

Other states have tried to limit visits, he said, but later abandoned the programs or used a much shorter list of nonemergency conditions.

Carol M. Ostrom: 206-464-2249 or [email protected] . On Twitter @costrom.

Coloringfolder.com

Will Medicaid Pay for an ER Visit Out of State? Everything You Need to Know

Are you planning a trip out of state but worried about your Medicaid coverage? Well, you’re not alone! Many people are concerned about whether or not their health benefits will cover emergency room visits outside their state. It’s a valid concern because nobody wants to end up with a hefty medical bill after an unexpected trip to the emergency room.

Fortunately, there is some good news. Medicaid coverage does extend outside of your home state, but there are some important factors to consider. Depending on the state you’re traveling to, coverage can vary, and you may need to follow specific procedures to get the care you need. So if you’re planning a trip in the near future, make sure to educate yourself on your Medicaid coverage and how to handle a medical emergency while you’re away from home.

In this article, we’ll explore what you need to know about your Medicaid coverage outside your state, and we’ll provide you with some helpful tips to prepare for any unexpected medical situations. From understanding the specific requirements of your Medicaid plan to knowing how to access emergency care, we’ve got you covered. By the end of this article, you’ll have all the information you need to confidently travel outside your home state and know exactly what to do if you need emergency medical assistance. Medicaid coverage across state lines

If you have Medicaid coverage and need emergency medical services while out of state, you may be wondering if your insurance will cover the cost. Each state has its own Medicaid program, but the good news is that Medicaid coverage can sometimes extend across state lines.

  • Medicaid coverage may be available in another state if you are traveling, temporarily working, or visiting family.
  • You may be required to follow certain rules or procedures to access Medicaid services in another state.
  • If you have a managed care Medicaid plan, you may need to get pre-authorization before seeking services out of state.

It is important to note that Medicaid coverage across state lines is typically limited to emergency services. Routine medical care may not be covered, and you may be responsible for finding a healthcare provider who accepts your insurance in the state where you are visiting.

If you need emergency medical services while out of state, it is important to seek care immediately. Your health and well-being should always be your top priority. After you have received care, be sure to contact your home state’s Medicaid program to report the emergency and find out how to submit a claim.

Emergency room visits and Medicaid

Emergency room visits can be a costly affair, especially for people with limited financial means. Fortunately, for those who are eligible, Medicaid provides coverage for emergency room visits. But what happens when you need emergency care while traveling out of state? Will Medicaid cover your emergency room visit if it takes place outside your home state?

  • The answer is yes.
  • Medicaid coverage extends to emergency care in all states.
  • However, there are certain rules and limitations that apply when you seek emergency care outside your home state.

Under federal law, Medicaid must cover emergency services for eligible individuals who are traveling outside their home state. Even if you are not currently enrolled in Medicaid, if you are eligible for coverage, you can receive emergency care in any state and have it covered by Medicaid.

However, it’s important to note that Medicaid only covers emergency care that is deemed medically necessary. This means that the care you receive must be required to evaluate or stabilize your condition. If the care you receive is not considered medically necessary, it may not be covered by Medicaid.

What to do if you need emergency care while traveling out of state?

If you need emergency care while traveling out of state, your first step should be to seek medical attention. Once you have received the necessary care, you or someone on your behalf should contact your state Medicaid office. You will need to provide details about the emergency care you received, including the date of service, the provider’s name and address, and a description of the services provided.

It’s important to keep in mind that each state has different rules and requirements when it comes to Medicaid coverage for emergency care outside the state. It’s advisable to contact your state Medicaid agency before traveling to find out what the rules are for emergency care in other states.

Limitations on coverage for emergency care outside the state

While Medicaid coverage extends to emergency care outside the state, there are certain limitations to be aware of:

It’s important to understand these limitations before seeking emergency care outside your home state. If you have any questions about Medicaid coverage for emergency care outside the state, contact your state Medicaid agency for more information.

Out of Network Coverage with Medicaid

Medicaid is a federal and state-funded health insurance program that aims to provide low-income individuals and families with access to healthcare services. While Medicaid covers a range of medical services, including emergency care, there are limitations to its coverage, particularly when it comes to out of network care.

When you seek medical care outside of your home state, you may need to visit a healthcare provider who is not in the Medicaid network. In this case, you may be wondering if Medicaid will pay for the out of state ER visit.

  • In some cases, Medicaid will pay for out of state care if it is deemed medically necessary. The healthcare provider will need to get approval from the state’s Medicaid program before providing the service.
  • If the out of state healthcare provider is not in the Medicaid network, you may have to pay for the medical care out of pocket and then submit a claim to your state’s Medicaid program for reimbursement.
  • Some states have reciprocity agreements with neighboring states, which means that Medicaid beneficiaries can receive emergency services in a nearby state without prior authorization from the state’s Medicaid program.

It’s important to note that if the out of network care is not deemed medically necessary or is not covered under your Medicaid plan, you may be responsible for the full cost of the medical care.

If you are planning to travel out of state and will need medical care, it’s wise to contact your state’s Medicaid program beforehand to learn about their out of network coverage policy and to ensure that you have the necessary documentation to receive coverage.

Overall, while Medicaid does provide coverage for emergency medical care, there are limitations to out of network coverage that vary by state. It’s important to be familiar with your state’s Medicaid program out of network coverage policy before seeking medical care outside of your home state.

Determining Eligibility for Medicaid Coverage

Medicaid is a government-funded health insurance program that provides coverage for millions of low-income and disabled individuals. But not everyone is eligible for Medicaid coverage, and the rules for eligibility can vary from state to state.

One of the most important factors for determining Medicaid eligibility is income. In most states, individuals with an income at or below 138% of the federal poverty level (FPL) are eligible for Medicaid. However, some states have expanded their Medicaid programs to cover individuals with incomes above this threshold. The FPL varies based on family size, so it’s important to check the guidelines for your state.

Other factors that can affect Medicaid eligibility include age, disability status, and citizenship or immigration status. For example, some states provide Medicaid coverage for pregnant women or children under certain income thresholds, regardless of immigration status.

  • Income is a key factor in determining Medicaid eligibility.
  • Most states have income thresholds based on the federal poverty level.
  • Other factors, such as age and disability status, can also affect eligibility.

If you think you might be eligible for Medicaid, it’s important to apply as soon as possible. You can apply online, by phone, or in person at your local Medicaid office. You may also be able to get help with the application process from a local organization or healthcare provider.

Once you are enrolled in Medicaid, it’s important to understand what services are covered. Medicaid typically covers a wide range of medical services, including doctor visits, hospital care, and prescription drugs. However, the specifics of your coverage may depend on your state and the type of Medicaid program you are enrolled in.

Overall, understanding Medicaid eligibility and coverage can be a complex process. But with the right information and resources, you can make informed decisions about your healthcare and access the services you need.

Medicaid reimbursement for emergency care

Medicaid is a government-funded health insurance program for low-income individuals and families. One of the benefits of being enrolled in Medicaid is that it covers emergency medical care. However, there are specific rules and regulations that apply to Medicaid reimbursement for emergency care.

  • Medicaid will only pay for emergency care that is deemed necessary by a medical professional. This means that if you go to the emergency room for a non-emergency condition, such as a sore throat, Medicaid will not cover the cost.
  • Medicaid will only cover emergency care that is received in an emergency room. If you go to an urgent care center or another healthcare facility, Medicaid may not cover the cost.
  • Medicaid will only cover emergency care that is received in the state where you are enrolled in Medicaid. If you are traveling out of state and require emergency medical care, Medicaid may not cover the cost.

It’s important to note that there are some exceptions to these rules. For example, if you are traveling out of state and require emergency medical care, Medicaid may cover the cost if you are unable to receive care in your home state. Additionally, Medicaid may cover emergency care received out of state if it is closer and more accessible than a facility in your home state.

Here is an example of how Medicaid reimbursement for emergency care works:

If you have questions about Medicaid reimbursement for emergency care, it’s important to contact your state Medicaid agency or healthcare provider for more information.

State Medicaid Programs and Coverage Options

Medicaid programs vary state by state, and coverage options may differ depending on the state of residence. Medicaid is a joint federal and state program that provides healthcare to eligible individuals and families with limited incomes. Funds for Medicaid are provided by both the federal government and the state government, with the state government responsible for managing the program locally.

  • Eligibility: The eligibility criteria for Medicaid can differ in each state. Generally, individuals with low income, pregnant women, children, and individuals with disabilities are eligible for Medicaid.
  • Coverage: Medicaid provides comprehensive healthcare services such as doctor visits, hospital stays, lab tests, prescription drugs, and more. However, coverage can vary depending on the state.
  • Out-of-State Coverage: Medicaid coverage may extend to out-of-state emergency care services. However, non-emergency services may not be covered. In some cases, prior authorization may be required.

If you are traveling out of state and require emergency medical care, your Medicaid coverage may apply. However, it’s essential to check with your Medicaid plan beforehand to understand what emergency services are covered and if there are any restrictions or limitations to receiving care out of state.

Below is a tentative table that illustrates the different types and areas that different states cover under Medicaid:

It’s important to be familiar with the Medicaid program in your state, as well as the coverage options available to you. Knowing what services are covered and how eligibility is determined can help ensure that you receive proper medical care when you need it most.

Impact of the Affordable Care Act on Medicaid coverage

One of the most significant changes brought about by the Affordable Care Act (ACA) was the expansion of Medicaid coverage. The ACA allowed for more individuals and families to be eligible for Medicaid, with a higher income threshold for qualification. As a result, millions more Americans gained access to healthcare through Medicaid.

  • One of the primary goals of the ACA was to decrease the number of uninsured individuals in the United States. Medicaid expansion helped to achieve this goal by providing coverage to those who previously could not afford healthcare or did not qualify for Medicaid under the stricter eligibility requirements.
  • However, not all states have chosen to expand Medicaid coverage under the ACA. As of 2021, 12 states have not expanded Medicaid, leaving millions of low-income residents without access to health insurance through this program.
  • Furthermore, the Medicaid program is facing continued threats of funding cuts at the federal level. As a result, it is more important than ever for individuals and families to understand their Medicaid coverage and eligibility requirements, especially when seeking medical treatment out of state.

When it comes to emergency room visits out of state, Medicaid coverage can vary based on several factors, including state policies and the type of medical treatment needed. In general, Medicaid will cover emergency medical treatment out of state if the treatment is deemed necessary and urgent. However, non-emergency medical treatment may not be covered, or may require prior authorization from the state Medicaid agency.

If you are seeking medical treatment out of state and are covered by Medicaid, it is essential to contact your state Medicaid agency or healthcare provider to understand your coverage options and any necessary requirements for receiving treatment. Additionally, it is essential to understand that Medicaid reimbursement rates may vary between states, potentially leading to higher out-of-pocket costs for patients.

Overall, the ACA brought about important changes to Medicaid coverage, allowing more individuals and families to access healthcare. However, ongoing threats of funding cuts and state-level policy decisions have meant that not all Americans have access to these crucial programs. When seeking medical treatment out of state, it is essential to understand Medicaid coverage options and requirements to ensure the best possible outcome for you and your family.

Will Medicaid Pay for ER Visit Out of State FAQs

1. does medicaid cover emergency room visits outside of my home state.

Yes, Medicaid covers emergency room visits outside of your home state as long as it is an emergency that cannot be delayed.

2. Do I need to get prior authorization before seeking emergency treatment out of state?

No, you do not need to get prior authorization before seeking emergency treatment out of state as long as it is an emergency.

3. Will Medicaid cover all the expenses for an emergency room visit out of state?

Medicaid will cover the expenses for emergency room visit out of state only if it is deemed medically necessary and reasonable.

4. Can I visit any emergency room out of my home state and expect Medicaid to cover it?

You can visit any emergency room outside of your home state that accepts Medicaid, and Medicaid will cover the expenses as long as the visit is deemed medically necessary.

5. Will Medicaid pay for emergency transportation to an out-of-state hospital?

Yes, Medicaid will pay for emergency transportation to an out-of-state hospital if it is deemed medically necessary.

6. How do I file a claim for an out-of-state emergency room visit?

You should notify your local Medicaid office of your out-of-state emergency room visit as soon as possible and provide them with all the necessary documents.

7. Can I be denied emergency room care out of state if I only have Medicaid?

No, you cannot be denied emergency room care out of state if you only have Medicaid. Emergency care is one of the guaranteed benefits of Medicaid.

Closing Thoughts

Thanks for taking the time to read this article about whether or not Medicaid covers emergency room visits out of state. It’s important to know your rights when it comes to healthcare, and we hope this article has been helpful in answering your questions. Remember, in case of an emergency, seek medical attention immediately, and if you have any further questions about Medicaid coverage, do not hesitate to contact your local Medicaid office. Come back soon for more informative articles!

  • Does Louisiana Medicaid Cover Out-of-State Emergencies?
  • Does Medicaid Pay for Room and Board in Assisted Living? Exploring the Benefits and Limitations
  • Does Medicaid Cover Urgent Care? All You Need to Know
  • Do I Automatically Qualify for Medicaid if I'm Pregnant? - Everything You Need to Know
  • How Often Does Medicaid Need to be Renewed? A Comprehensive Guide
  • Can Undocumented Immigrants Apply for Medicaid? Exploring Your Healthcare Options
  • Hillsborough

Move to kill Hillsborough County’s indigent care tax stalls

  • William March Times correspondent

A move by Republican Hillsborough County Commissioner Josh Wostal to eliminate the county’s indigent health care tax has hit a dead end in this year’s legislative session.

Wostal proposed the move to the county’s legislative delegation in a September meeting, contending that the tax is illegal because it was not voted on in a referendum.

State Rep. Mike Beltran, R-Riverview, filed legislation to achieve Wostal’s goal.

“The county government shouldn’t tax us, we should tax ourselves,” Beltran said.

But with the session nearing its end, his bill stalled without getting a committee hearing, Beltran said last week.

The half-cent sales tax, largely the brainchild of the late Commissioner Phyllis Busansky, was enacted in 1991 by a supermajority vote of commissioners.

Wostal contended that it’s the only county tax in the state enacted without a popular vote, calling it “taxation with representation.”

“I’m confident that the strong leadership (in the delegation) will work with me diligently to make sure that this cycle is the last cycle that we illegally tax residents of Hillsborough County,” he said.

He said it has large reserves because “we could not find places to use it.”

Gene Earley, county director of health care services, said the tax is projected to produce about $156 million this year, and the reserve fund is now $366 million.

Earley said the reserve fund “has fluctuated considerably over the years” and is intended to make sure the plan can “overcome factors like economic slowdowns, inflation, increases or decreases in enrollment, etc.”

Spending cuts in the program were required as the reserve fund was depleted during the 2007-09 recession, but it has grown recently because of “a short-term dip in enrollment” and increased consumer spending as the pandemic ended, he said.

Republicans currently have a 4-3 commission majority but ending the indigent health care program would be controversial.

Democrats say the program helps provide coverage for those who make too much money to qualify for Medicaid, but not enough to qualify for subsidized insurance under the Affordable Care Act, and thus helps cut down unnecessary emergency room visits.

William March is a Times correspondent who writes about politics.

MORE FOR YOU

  • Advertisement

ONLY AVAILABLE FOR SUBSCRIBERS

The Tampa Bay Times e-Newspaper is a digital replica of the printed paper seven days a week that is available to read on desktop, mobile, and our app for subscribers only. To enjoy the e-Newspaper every day, please subscribe.

IMAGES

  1. ER visits did not rise with Medicaid expansion under Affordable Care Act

    er visits with medicaid

  2. Does Medicaid Cover ER Visits ?

    er visits with medicaid

  3. Medicaid Monday: Managed Care Reduces ER Visits

    er visits with medicaid

  4. Study: With Medicaid, ER visits remain high for two years

    er visits with medicaid

  5. Study: Rise in ER visits after Medicaid expansion

    er visits with medicaid

  6. Does Medicaid Cover ER Visits?

    er visits with medicaid

VIDEO

  1. NJSpotlight: The Impact of Medicaid Expansion on New Jersey's Healthcare System

  2. Health Benefit Exchange 101

COMMENTS

  1. Does Medicaid Cover Emergency Room Visits?

    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 ...

  2. Does Medicaid Cover Emergency Room Visits?

    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 ...

  3. Does Medicaid Cover ER Visits?

    Medicaid does not automatically pay for urgent care visits. To be covered, the clinic must be enrolled as an authorized Medicaid biller in your state, and a doctor at the clinic must certify that your visit was a medical necessity that fell between an elective office visit and a serious emergency requiring ER care.

  4. The Complete Guide to Emergency Services Covered by Medicaid

    Medicaid covers a wide range of emergency services, which may vary slightly from state to state. However, the program typically covers the following emergency services: Emergency room visits. Ambulance transportation. Emergency surgeries. Diagnostic tests and imaging. Emergency dental care.

  5. Medicaid and Emergency Room Use

    CMS gives states the option to charge Medicaid patients up to $8 if they visit an ER without having a true medical emergency. But, as of 2020, only fourteen states enforced this copayment ...

  6. Medicaid Expansion Use and Avoidable Emergency Department Use

    In this study, the authors examined 80.6 million outpatient ED visits from the Healthcare Cost and Utilization Project State Emergency Department Databases and a difference-in-differences design to evaluate changes in the rate of outpatient ED use in 2 Medicaid expansion states (New York and Massachusetts) vs 2 nonexpansion states (Georgia and ...

  7. Does Medicaid Cover ER Visits?

    Medicaid will always cover emergency room visits, but the way visits are covered varies depending on your state. There are two sets of Medicaid benefits: mandatory benefits that the federal government requires, and optional benefits offered by the state. Emergency room care is a mandatory benefit, so no matter which state you live in you are ...

  8. Comparing Emergency Department Use Among Medicaid and Commercial

    Introduction. T he high rate of emergency department (ED) use by Medicaid enrollees has been a long-standing concern among policy makers. 1-4 State Medicaid programs have proposed different policies to reduce ED visits including requiring Medicaid patients to make higher co-payments for their ED visits or providing Medicaid patients with robust alternative services to ED care through patient ...

  9. Having Medicaid increases emergency room visits

    The study, published January 2, 2014 in the journal Science, also documents that having Medicaid consistently increases visits to the emergency room across a range of demographic groups, types of visits, and medical conditions, including types of conditions that may be most readily treatable in primary-care situations.

  10. As Medicaid Shrinks, Clinics for the Poor Are Trying to Survive

    She recently received a bill of almost $8,000 for an emergency room visit Raylan had after losing Medicaid coverage, she said. To stay financially afloat, the clinic works to see as many patients ...

  11. Medicaid expansion increased emergency room visits, study finds

    Patients with Medicaid made, on average, 1.43 ER visits, compared with 1.02 for those who lost the lottery, an increase of 40 percent. The study also found that 35 percent of people who weren't ...

  12. Products

    Data from the National Hospital Ambulatory Medical Care Survey, 2019. The overall emergency department (ED) visit rate (47 visits per 100 people in 2019) and visit rates by metropolitan statistical area (MSA) status did not change between 2009 and 2019. The ED visit rate was highest for infants under age 1 year (123 visits per 100 people ...

  13. Products

    Data from the National Hospital Ambulatory Medical Care Survey. The overall emergency department (ED) visit rate was 40 visits per 100 people in 2020. The ED visit rate was highest for infants under age 1 year (68 visits per 100 infants), followed by adults aged 75 and over (63 per 100 people). The ED visit rate for non-Hispanic Black or ...

  14. Estimates of Emergency Department Visits in the United States, 2016-2021

    This visualization depicts both counts and rates of emergency department visits from 2016-2021 for the 10 leading primary diagnoses and reasons for visit, stratified by selected patient and hospital characteristics. Rankings for the 10 leading categories were identified using weighted data from 2021 and were then assessed in prior years ...

  15. Study: With Medicaid, ER visits remain high for two years

    Washington Post reporter Carolyn Johnson writes that a study by Prof. Amy Finkelstein finds that expanding Medicaid access increases emergency room visits."People who gained Medicaid visited the emergency room about 65 percent more often than individuals who did not gain Medicaid in the first six months -- and the trend continued out to two years."

  16. MAC Scorecard

    The Centers for Medicare & Medicaid Services (CMS) developed the Medicaid and Children's Health Insurance Program (CHIP) Scorecard to improve transparency and accountability about the administration and outcomes of these programs. States and CMS can use the Medicaid and CHIP (MAC) Scorecard to drive improvements in areas such as state and ...

  17. Here's what Texans need to do to avoid losing Medicaid coverage

    The U.S. Department of Health and Human Services predicts that as many as 15 million people nationwide could be disenrolled in Medicaid during this process, including 6.8 million who still qualify ...

  18. Study: Most Seniors' ER Visits Could Be Avoided

    Hospitals in 2006 spent $30.8 billion on 4.4 million hospital admissions that might have been avoidable, according to a report by the federal Agency for Healthcare Research and Quality. A 2006 Rutgers University study found 47 percent of ER visits in New Jersey were potentially avoidable.

  19. Medicaid Expansion Causes Surge In ER Visits

    Medicaid increased ER visits by 40% in the first 15 months. There is no evidence that the increase in ER use is driven by pent-up demand that dissipates over time; instead, the effect of Medicaid ...

  20. Emergency Medicaid

    Phone: Call 800-221-3943 (State Relay: 711). Phone applications are available Monday through Friday from 8 a.m. to 4 p.m. Mail: Download and print a paper application. (Available in English and Spanish). In person: Apply in person at your county's Department of Human Services or a local application assistance site.

  21. Medicaid patients now have 12 months of postpartum coverage in Texas

    A new Medicaid extension goes into effect today that gives pregnant Texans twelve months ... "It's decreased a lot of unnecessary ER visits because you're having that follow-up care with ...

  22. Is housing health care? State Medicaid programs increasingly say 'yes'

    That program slashed ER visits 45% and reduced hospital inpatient admissions 53% at the six-month mark after patients started receiving services, while increasing less costly preventive care 56% ...

  23. State Medicaid program to stop paying for unneeded ER visits

    The rules — arguably more drastic than an earlier proposal to limit Medicaid patients to three visits per year for nonemergency conditions — would block payment for ER visits for about 500 ...

  24. Hospital Emergency Services

    Yes. Hospital emergency services are available to Health First Colorado (Colorado's Medicaid Program) members. Emergency services are needed when symptoms are so severe that the absence of immediate medical attention could reasonably be expected to seriously jeopardize the patient's health or the bodily functions of any bodily organ or part.

  25. Emergency

    Emergency Room visits, Eligibility and Copays. IBM WebSphere Portal. An official State of Ohio site. Here's how you know ... Ohio Department of Medicaid | 50 West Town Street, Suite 400, Columbus, Ohio 43215. Consumer Hotline: 800-324-8680 | Provider Integrated Helpdesk: 800-686-1516.

  26. Medicaid for the Treatment of an Emergency Medical Condition Fact Sheet

    Medicaid payment is provided for care and services necessary for the treatment of an emergency medical condition, to certain temporary non-immigrants (e.g., certain foreign students, visitors/tourists) who are otherwise eligible and undocumented non-citizens. An undocumented non-citizen must meet all eligibility requirements, including proof of ...

  27. US kidney care is broken. But we have the means to fix it

    As many as 60 percent of people with late-stage kidney disease "crash" into the emergency room with failed kidneys, needing emergency dialysis to survive. Each crash leads to poorer outcomes ...

  28. Will Medicaid Pay For An ER Visit Out Of State? Everything You Need To

    When it comes to emergency room visits out of state, Medicaid coverage can vary based on several factors, including state policies and the type of medical treatment needed. In general, Medicaid will cover emergency medical treatment out of state if the treatment is deemed necessary and urgent. However, non-emergency medical treatment may not be ...

  29. Move to kill Hillsborough County's indigent care tax stalls

    A move by Republican Hillsborough County Commissioner Josh Wostal to eliminate the county's indigent health care tax has hit a dead end in this year's legislative session. Wostal proposed the ...