Medicare Part B usually covers emergency room (ER) visits, unless a doctor admits a person to the hospital for a certain length of time.
For inpatient admissions, Medicare Part A may cover the ER visit and subsequent hospital stay if the length of admission into hospital spans at least 2 midnights.
In this article, we break down how Medicare divides costs for ER visits, including different coverage scenarios.
Medicare plans consist of different parts that account for various areas of healthcare. These parts cover different aspects of emergency care.
ER visits may involve treatment for acute injuries, sudden illnesses, or potentially life threatening conditions, including heart attack and stroke.
Medicare Part A
Medicare Part A provides hospital coverage. If a doctor admits an individual into the hospital for at least 2 midnights, Medicare Part A covers hospital services, such as accommodation costs and testing, while a person stays in the facility.
If Medicare Part A pays for the hospital visit, a person is responsible for a deductible of $1,260. A deductible is a spending total that a person must self-fund on a policy before coverage commences.
Once a person spends this amount out of pocket on treatment, Medicare Part A pays 100% of the hospital costs for up to 60 days.
A person with Medicare Part A may also have to pay copayments for the medical services that they receive. A copayment is a fixed percentage of treatment costs.
Medicare Part B
Medicare Part B is the portion of Medicare that most often covers ER visits if the doctor does not request inpatient admission.
An exception would be if one of the following scenarios occurs:
- A person goes to the ER, and the doctor discharges them.
- The health problem returns, and the individual needs to go back to the ER within 3 days.
- The doctor admits the person. In this example, Medicare Part A would pay for the hospital stay.
When Medicare Part B covers the ER visit, a person is usually responsible for a portion of the costs. Examples of these costs include:
- a copayment for the emergency department visit and hospital services
- covering 20% of the funds that Medicare approves for doctor’s services
- the Part B deductible
These copayments and deductibles may vary on a yearly basis.
Medicare Part C, or Medicare Advantage
Medicare Part C, or Medicare Advantage, is a bundled plan that includes Parts A, B, and D, as well as some additional services that depend on the plan that a person chooses.
Private insurance companies offer Medicare Advantage plans. How these plans cover the costs of an ER visit is similar to how traditional Medicare covers them.
However, a Medicare Advantage plan may structure the billing and costs differently than traditional Medicare. For example, the plan may ask a person to pay one copayment per visit that accounts for both the emergency room and the doctor.
Medicare Part D
Medicare Part D is a Medicare plan that helps people fund prescription medications.
If an individual receives medications in the ER, Medicare Part D may pay for them if they are on the person’s list of covered medications.
Medicare Supplement, or Medigap
Medicare supplement, or Medigap, policies may provide emergency health coverage if a person is traveling outside the United States.
Traditional Medicare does not traditionally cover costs for emergency care if a person is traveling outside the country.
Only certain Medigap policies cover this cost, so a person who travels frequently may wish to choose one that does.
Sometimes, a blend of Medicare Parts A and B will cover aspects of an ER visit. The following are some example scenarios:
Scenario: An ambulance brought you to the ER.
What pays: Medicare Part B generally covers ambulance transportation to a hospital, skilled nursing facility, or critical access hospital. The ambulance service will take you to the nearest appropriate medical facility, depending on your symptoms.
However, if you called the ambulance in a situation that is not an emergency, or the ambulance service believes that Medicare may not cover your ambulance trip, the ambulance service will provide you with a notice called an “Advance Beneficiary Notice of Noncoverage.”
Scenario: You go to the hospital for severe abdominal pain. The first night, you are at the hospital under “observation,” then the doctor decides to admit you to the hospital the next day.
What pays: Part A will cover your inpatient hospital stay, as well as the services that you received in the 3 days before your hospital admission. However, Part B will pay for the doctor’s services while you are in the hospital.
Scenario: You are in the ER, and a doctor writes an order to admit you to the hospital.
What pays: Part A will pay for your hospital stay and the services that you received when you were an outpatient. However, Part B will pay for your doctor’s services.
It is important to remember that staying overnight at an ER does not automatically qualify a person as an inpatient.
The hospital or freestanding emergency department should confirm during the visit whether or not they are providing treatment on an inpatient basis. If a person is not an inpatient, Part B is the insurance portion that covers the services.
In a 2018 study of Medicare beneficiaries who were 65 years of age or older and sought treatment at an ER, the authors estimated that the healthcare provider broke down treatment in the following ways:
- They discharged 48% of people.
- The doctor kept 10.5% of people in for observation.
- The facility admitted 41.5% of people as inpatients.
According to the study, the most common reasons for hospital admission were ischemic heart disease and renal disease.
Medicare beneficiaries made between 4.2 and 5.3 million visits — depending on the definition — to an ER in 2012, according to an article in the journal Academic Emergency Medicine.
While very little data are available that relate specifically to the ER expenses of Medicare beneficiaries, the overall average cost of an ER visit is $1,917, according to the Healthcare Financial Management Association.
Medicare plans have different parts that cover various emergency room services. Unless a doctor admits a person to the hospital, Part B will generally cover most ER-related costs.
When a person seeks ER care, they can ask for an estimate of service costs at any time, including charges for testing or doctor consultation fees.
Doing this may help reduce the stress of an ER visit and set expectations as to how much of a person’s own money they will have to spend on treatment.
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