I have a Medicaid plan. They denied my ER visit, or the hospital bills me. Is that allowed?

Health insuranceDeniedChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: GovInfo · 42 CFR § 438.114 «Emergency and post-stabilization services» · paragraphs (c), (d) View original ↗

In short

A Medicaid plan must pay for emergency care, even out of network.
It can't use a list of diagnoses to say what is an emergency.
You can't be held liable for care that finds or treats an emergency.

What this means

This is about Medicaid managed care plans, under a federal rule (42 CFR 438.114). The plan must pay for emergency services, even if the hospital is not in its network [1]. It may not deny payment if you had an emergency. It may not deny payment if a plan worker told you to seek emergency care [1].

The plan may not use lists of diagnoses or symptoms to decide what is an emergency [1]. It may not refuse to pay because the hospital was late to tell your primary care provider or the plan. The limit is 10 calendar days [1]. If you have an emergency, you may not be held liable for the later care to diagnose or stabilize you [1].

Your next step

If the plan denied the ER claim, ask for the denial in writing and follow the appeal steps in the notice. If a hospital bills you, send the bill to the plan and ask what you owe. This does not cover Medicaid that is not run by a managed care plan. Your state may have its own rules. The sources give no deadline.

Check it yourself

Open GovInfo, 42 CFR § 438.114, at https://www.govinfo.gov/content/pkg/CFR-2025-title42-vol4/xml/CFR-2025-title42-vol4-sec438-114.xml and read the part quoted above. Your own plan or policy papers hold details these sources do not give: "Don't know yet" for your case.

Where this comes from (1)

[1] GovInfo · 42 CFR § 438.114 «Emergency and post-stabilization services» · paragraphs (c), (d) · checked 2026-11-06
Must cover and pay for emergency services regardless of whether the provider that furnishes the services has a contract with the MCO, PIHP, PAHP, PCCM or PCCM entity … May not deny payment for treatment obtained under either of the following circumstances: ( A ) An enrollee had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified…

How we found this

We matched your question to 1 official source, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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