How do hospitals bill and get reimbursed for emergency care provided to undocumented immigrants under federal rules?
Executive summary
Hospitals must provide stabilizing emergency care to anyone who presents at an emergency department under EMTALA; when the patient is an undocumented immigrant, that care can be billed to Emergency Medicaid (which reimburses providers, not the patient) if the patient meets Medicaid financial and non‑immigration eligibility rules, with states submitting claims to Medicaid and receiving a federal match that recent law has reduced for some cases (shifting more cost to states) [1] [2] [3] [4].
1. EMTALA creates the duty to treat first and bill later
Federal law known as the Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals with emergency departments to screen and provide stabilizing treatment for emergency medical conditions regardless of a patient’s ability to pay or immigration status; that duty is the trigger that leads hospitals to seek reimbursement after care is delivered rather than to deny treatment up front [1] [3].
2. Emergency Medicaid: the vehicle for reimbursing hospitals, not patients
When an uninsured immigrant would otherwise qualify for Medicaid except for immigration status, the hospital can bill Emergency Medicaid for services that meet the program’s definition of emergency care (stabilization and related inpatient/outpatient services); Emergency Medicaid reimburses providers, not the noncitizen, and is narrowly focused on life‑ or limb‑saving care [2] [5] [6] [7].
3. States file claims; federal matching payments cover most — but changing — shares
Emergency Medicaid operates through state Medicaid programs: states determine qualifying services, submit claims, and receive federal matching funds (FMAP) for reimbursing hospitals; historically the federal match for emergency services tied to expansion populations was higher (up to 90% in some temporary rules), but legislation in 2025 reduced the federal matching rate for certain emergency services for immigrants who would otherwise be eligible for expanded Medicaid, effective October 1, 2026, shifting a larger share of costs to states [8] [5] [4] [9].
4. What counts as reimbursable emergency care — federal baseline, state details
Reimbursable services under Emergency Medicaid generally mirror what EMTALA requires (screening, stabilization, and related inpatient/outpatient services including labor and delivery in many states), but states define the specifics and procedural rules for eligibility and billing, so the concrete list of reimbursable items and documentation requirements varies across jurisdictions [2] [10] [7].
5. When reimbursement fails or is limited: uncompensated care and state choices
If Emergency Medicaid does not cover the encounter — because the condition is not considered an emergency, the patient fails other Medicaid eligibility tests, or state policy excludes a service — hospitals may bill the patient (who is unlikely to be eligible for Medicaid) and absorb uncompensated costs, seek payment via state‑only programs, or pursue other payers; Congress’s budget changes do not remove the duty to treat but can reduce federal reimbursements, increasing uncompensated care pressure on hospitals and states [11] [9] [6].
6. Political and policy contention changes the dollar flows, not the duty to treat
Reporting and fact‑checks across sources emphasize that federal law still requires emergency stabilization regardless of immigration status and that Emergency Medicaid pays hospitals rather than immigrants, but policy changes (notably in the 2025 reconciliation legislation) alter how much the federal government contributes to reimbursements for certain groups — an explicit fiscal shift often framed politically as either protecting taxpayers or cutting hospital support, depending on the source (see NILC, KFF, Politifact, American Immigration Council) [12] [9] [13] [6].
7. Reporting limits and practical implications
Public sources provide a clear framework for billing and reimbursement but do not enumerate every administrative step hospitals follow locally — such as intake screening protocols for immigration status, timelines for state claims, or how specific hospitals manage unpaid balances — and those operational details vary by state and hospital system [1] [10] [2].