How do I stack a 403(b) and a 457(b) at a hospital emergency medicine job?
By Ryan Inman
Published · Updated
The short answer
Fill both plans, in order, when a county or public academic emergency job offers them, because the two plans carry separate limits rather than sharing one. The two deferral limits are separate: $24,500 each for 2026. The 403(b) elective deferral limit for 2026 is $24,500, and the governmental 457(b) elective deferral limit for 2026 is its own $24,500, per Internal Revenue Service Notice 2025-67.
Added together, the stack shelters $24,500 plus $24,500, which is $49,000 of salary a year, before the health savings account and the backdoor Roth IRA are counted. Emergency medicine meets this stack in a specific set of workplaces: county hospitals, public systems, and state university medical centers, where the employer is a government entity and the 457(b) on the benefits sheet is the governmental kind. That last word, governmental, is the whole ballgame, and the first section below tells you how to check it.
Part of the emergency medicine hub.
Read the label before you count the room
The stack exists in its full form only if the 457(b) is governmental. A governmental 457(b) is offered by a state, county, or public agency employer. Its assets are held in trust for you, apart from the employer finances. A 457(b) offered by a private nonprofit system is a different instrument: an unfunded promise, exposed to the employer creditors, with more restrictive distribution rules. Many large nonprofit systems employ emergency physicians directly, and their benefits sheets can list a 403(b) and a 457(b) side by side in a way that looks identical to the county offer. It is not identical. Ask your benefits office one direct question: is this a governmental 457(b) plan? Get the answer from the plan document, not from a recruiting summary.
The label matters to the offer comparison as well. Marit Health, from 1,905 self reported emergency medicine salaries in October 2026, reports government and military emergency physicians averaging $349,000, and academic practice averaging $399,500 against $449,000 for non academic practice. A reader comparing offers on salary alone will mark the county and academic offers down. Where the employer is public, the stack is part of what that comparison misses. A second $24,500 room of deferral, every year, for a whole career, is compensation that never appears on the salary line.
The order inside the waterfall
The stack sits inside the max retirement tier of Ryan's waterfall, and the waterfall order governs it. Capture the full employer match first, wherever the match lives, because matched dollars pay a 100 percent return. Fund the backdoor Roth IRA, at the $7,500 limit for 2026, at its own earlier rung. Then, inside the max tier: the health savings account first, at $4,400 for self only coverage or $8,750 for family coverage in 2026, per Internal Revenue Service Revenue Procedure 2025-19, because its money is taxed at neither end when it pays for medical care. Then the 403(b) to $24,500. Then the governmental 457(b) to its own $24,500. Then mega backdoor space, where the plan allows it, last.
Now add the full sheltered year for a household at a county or public academic job, with family health coverage. The health savings account contributes $8,750. The two deferrals contribute $49,000. The backdoor Roth IRA contributes $7,500. The total is $8,750 plus $49,000 plus $7,500, which is $65,250 of gross income routed out of the current tax year or into permanent tax free growth, before any employer match is counted. The full rung by rung sequence, including where the reserve and the loan plan sit around this tier, is worked in the funding order question.
The governmental 457(b) separation quirk
The governmental 457(b) carries one property the 403(b) does not, and for emergency physicians planning an exit ramp, it may be the most valuable sentence on this page. Once you separate from the employer, a governmental 457(b) balance can be withdrawn with income tax due and no 10 percent early withdrawal penalty, at any age. Most other retirement accounts add that penalty to withdrawals taken before their standard ages. The 457(b) does not, once separation has happened.
Read that property against the shape of an emergency medicine career. This is a specialty with a real burnout curve, where cutting shifts in your forties and leaving clinical work earlier than a traditional retirement age are live plans, worked on the established pages of this hub. An account that can fund the gap years between separation and the age when other accounts open, without a penalty layer, is a bridge built into the benefits sheet. Two cautions keep the property honest. First, no penalty is not no tax: every withdrawal is taxed as income in the year it lands. Second, the quirk belongs to the governmental plan at separation. Roll the balance into an IRA and it takes on IRA rules. Before rolling anything at a job change, ask what property you are giving up.
The main points
- A 403(b) and a governmental 457(b) carry separate $24,500 deferral limits for 2026: $49,000 of shelter at one county or public academic emergency job, where offered.
- With the family health savings account at $8,750 and the backdoor Roth IRA at $7,500, the full stack shelters $65,250 a year before the match is counted.
- Read the 457(b) label first. The trust protection and the separation property belong to the governmental plan. The nonprofit plan is a different instrument.
- After separation, a governmental 457(b) can be withdrawn with income tax due and no early withdrawal penalty, at any age. Do not roll that property away without asking what it is worth.
Related questions
My hospital is a private nonprofit. Do I get the same stack?
You may get two deferral rooms, if the system offers both plans, and the $24,500 plus $24,500 arithmetic can still work. You do not get the governmental plan trust protection or its clean separation property, and the nonprofit 457(b) balance is exposed to the employer creditors. That risk read deserves its own conversation before you max the second room.
Which plan should I fill first if I cannot fill both yet?
The 403(b), in almost every case, because the employer match usually lives there and the match is captured at the first rung of the waterfall. Once the 403(b) is full, direct the next dollars to the 457(b). If your employer matches in an unusual place, follow the match.
Sources
- Internal Revenue Service, Notice 2025-67, which establishes the 2026 elective deferral limit of $24,500 for both 403(b) plans and governmental 457(b) plans, and the IRA limit of $7,500, accessed October 2026.
- Internal Revenue Service, Revenue Procedure 2025-19, which establishes the 2026 health savings account limits of $4,400 self only and $8,750 family, accessed October 2026.
- Marit Health emergency medicine salary data, 1,905 self reported salaries, October 2026, which establishes the government and academic compensation averages used in the offer comparison, accessed October 2026.