Duke Is Building a $32 Million ER With No Inpatient Beds. A Medicare Patient Who Needs Admission May Pay for the ER, the Ambulance and the Hospital

Duke Health has received approval for a $32 million, 24-hour freestanding emergency department in Garner. It will treat chest pain, strokes and broken hips. It has no inpatient beds. That matters most to Medicare patients who need hospital admission.

Imagine a 72-year-old on Original Medicare arrives with chest pain and the Garner team stabilizes her, calls an ambulance and sends her to a hospital for admission. In one afternoon she can move through an ER, an ambulance and an inpatient hospital stay. Whether Medicare bills those as three separate pieces depends partly on where she is admitted.

One Emergency Can Produce Three Medicare Bills

First comes the ER. Because the Garner site has no inpatient beds, the emergency visit begins as outpatient care under Part B. Patients pay a copayment for each emergency department visit and a copayment for each hospital service. After the Part B deductible, they also pay 20% of the Medicare-approved amount for doctors’ services. That deductible is $283 in 2026. Each hospital outpatient copayment can’t be more than the Part A deductible for each service.

Bill two: the ambulance. Part B covers medically necessary ground transport. After the deductible, patients pay 20% of the Medicare-approved amount. Medicare covers only a ride to the nearest appropriate medical facility that can treat the patient.

Bill three: the hospital. Part A takes over once a doctor writes an inpatient order. The inpatient deductible is $1,736 in 2026, up from $1,676 in 2025. It covers a patient’s share of the first 60 days of a benefit period.

If she has not already met her Part B deductible, the $283 Part B deductible and $1,736 Part A deductible could both come into play. ER copays, physician charges and ambulance coinsurance can add more.

Where the Ambulance Takes You Decides the ER Bill

Medicare can sometimes fold emergency care into a later inpatient stay instead of charging it separately. In this instance, Duke’s Garner emergency department will operate under Duke Raleigh Hospital, even though it has no inpatient beds.

If she needs admission, she will need to be transferred. Whether the Garner ER charges get folded into that hospital stay or remain separate can depend on where she goes and how the facilities are connected. Before the new ER opens, that billing relationship is worth confirming.

Observation Status Keeps the Hospital Stay on Part B

Admission to the second hospital does not guarantee inpatient status. Medicare counts emergency or observation services, which may include an overnight stay, as outpatient care. A patient under observation pays Part B copays service by service, plus 20% of physician fees, instead of one Part A deductible. Observation days generally do not count toward the three-day inpatient stay Original Medicare requires before covering skilled nursing care afterward.

Your Supplement Decides How Much of This Reaches You

• Original Medicare, no supplement: You face every layer above.
• Medigap Plan G: It pays the Part A deductible and Part B coinsurance or copayment. Your exposure drops to the $283 Part B deductible if not yet met this year.
• Medigap Plan N: You owe up to $50 for emergency room visits when you aren’t admitted as an inpatient.
• Medicare Advantage: Your plan sets its own ER, ambulance and hospital copays. Check whether the ER copay drops when you’re admitted, and whether that applies at another facility.

Three Steps to Take Before You Need the ER

1. Know where a serious case may go next. Once the Garner ER opens, ask Duke where patients who need admission are typically transferred and whether the ER charges are folded into that hospital stay. A transfer does not automatically mean a separate ER bill.
2. Close the gap during open enrollment this fall. If you have Advantage, compare plans’ ER, ambulance and inpatient copays. If you have Original Medicare with no supplement, price Plan G. Outside your Medigap open enrollment period, insurance companies can review your health history and deny coverage, so check North Carolina’s rules first.
3. Ask about your status in writing. At the receiving hospital, ask whether you are an inpatient or under observation. The answer decides whether Part A or Part B pays and whether nursing care afterward is covered.

A freestanding ER can deliver real emergency care. With no inpatient beds, though, a serious case takes its Medicare bill to the next building, and the one after that.

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