Emergency Room Copayments and Facility Billing Rules Under QMB

An emergency room visit can generate immediate financial anxiety for Medicare beneficiaries facing hospital facility copayments, physician billing, and diagnostic fees. For individuals enrolled in the Qualified Medicare Beneficiary program, federal law eliminates all out-of-pocket medical expenses for emergency room care. Providers are prohibited from billing QMB patients for covered Medicare emergency services.

Medicare cost sharing for emergency room visits

Under Original Medicare Part B, an emergency room visit carries several distinct charges under standard Medicare emergency coverage rules:

• Hospital emergency department facility copayment, typically around $100 to $150 per visit.
• Part B 20% coinsurance for emergency room physicians, trauma surgeons, and consulting specialists.
• Part B 20% coinsurance for diagnostic tests, including CT scans, MRI imaging, EKGs, and laboratory blood draws.
• Separate coinsurance for emergency ambulance transportation to the hospital facility.

Complete waiver of cost sharing under QMB statute

Under Section 1902(n)(3)(B) of the Social Security Act and detailed CMS QMB program directives, Medicare-participating hospitals, physicians, and ambulance suppliers cannot charge QMB beneficiaries for Medicare Part A or Part B cost sharing. When an emergency patient has QMB status:

• The emergency room facility copayment is reduced to $0.
• Doctor and specialist 20% coinsurance charges are reduced to $0.
• Imaging, blood tests, and medication administered in the ER are covered at $0.
• Providers must bill Medicare and state Medicaid directly and write off any remaining unpaid balance.

Emergency Medical Treatment and Labor Act protections

Under the federal Emergency Medical Treatment and Labor Act (EMTALA), every Medicare-participating hospital with an emergency department must provide an appropriate medical screening examination and stabilizing treatment regardless of insurance status or ability to pay. Hospital registration desks cannot delay emergency screening or care to collect copayments or demand advance deposits from QMB patients.

What should you do if an emergency physician bills you?

1. Do not pay the bill, as paying can make recovering your funds difficult.
2. Call the billing department number listed on the invoice and state clearly that you are a Qualified Medicare Beneficiary protected under federal law.
3. Provide your state Medicaid or QMB identification number and instruct them to bill your state Medicaid agency as secondary payer.
4. Report continuing billing violations or collection threats directly to 1-800-MEDICARE.

To review your rights when dealing with hospital observation stays following an ER visit, read our guide on QMB hospital stays and observation status and check your tier with our free MSP screener.

Frequently asked questions