Medicare covers emergency room visits within the United States and its territories. Out-of-pocket costs differ between original Medicare and Medicare Advantage plans.
Medicare covers emergency room visits primarily under original Medicare’s Part B. This article discusses this coverage, along with coverage options under Medicare Advantage and Medigap plans.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Original Medicare includes Part A, which is hospital insurance, and Part B, which is medical insurance. Part B covers an emergency room visit, including doctor services, medical tests, and IV medications.
Part B also covers outpatient costs for emergency and urgent care visits. Medicare may cover a person on an outpatient basis if, for example, they go to the ER, but the doctor sends them home and does not write an order to admit them.
For an emergency room visit in 2021, these costs include a $203 deductible and a 20% coinsurance.
If a person returns to the hospital within 3 days of their emergency room visit for related treatment, they will not need to pay the coinsurance. This is because Part A will cover the visit as an inpatient hospital stay. Generally, the out-of-pocket costs include a $1,484 deductible for the first 60 days.
Medicare Advantage (Part C) is the alternative to original Medicare and provides the same benefits. Advantage plans cover emergency room visits, but the rules of coverage and out-of-pocket costs differ from those of original Medicare.
With Medicare Advantage, regardless of whether a person goes to an in-network or out-of-network provider, they will usually either pay their in-network cost for emergency care or a $50 fee, whichever is lower.
However, people should check their policies to determine their exact coverage and costs.
Medigap, a Medicare insurance supplement, is available only for people enrolled in original Medicare. A person with a Medicare Advantage plan is not eligible to enroll in Medigap.
Medigap pays some of the out-of-pocket costs of Medicare parts A and B, including those for emergency room visits.
In addition, some Medigap plans offer coverage of foreign ER visits. This area of coverage is broader than the limited coverage of original Medicare and Medicare Advantage.
However, a requirement for this coverage is that emergency care must begin during the first 60 days of a person’s trip. The coverage has a lifetime limit of $50,000. Out-of-pocket expenses in 2021 include a $250 annual deductible and 20% of billed charges for medically necessary emergency care.
Medigap plans C, D, F, G, M, and N offer this benefit. Although plans E, H, I, and J are no longer available for purchase, an individual with one of these plans also receives foreign emergency care coverage.
An individual may need a combination of Medicare parts A and B to cover aspects of an emergency room visit. The following are some example scenarios:
Scenario: An ambulance takes a person to the ER.
What pays: Medicare Part B typically covers ambulance transport to a medical facility. It may then transport the individual to another appropriate facility, depending on their symptoms.
The ambulance service provides a notice called an Advance Beneficiary Notice of Noncoverage if they do not believe Medicare provides coverage. This could occur if the individual called them in a non-emergency situation.
Scenario: A person goes to the hospital for severe head pain. The doctor keeps the individual at the hospital under observation, then admits them to the hospital the next day.
What pays: Part A covers the inpatient hospital stay and the services the person received in the 3 days before the admission. However, Part B pays for the doctor’s services while in the hospital.
Scenario: Someone is in the ER, and a doctor writes an order to admit them to the hospital.
What pays: Part A pays for the hospital stay and the services received when the individual was an outpatient. However, Part B pays for doctor’s services.
Staying overnight in the ER does not automatically qualify someone as an inpatient. The ER should confirm during the visit if they are providing treatment on an inpatient basis. If an individual is an outpatient, Part B covers the services.
With original Medicare, the coverage of emergency room and urgent care visits falls under Part B. The costs include a 20% coinsurance after paying the annual deductible of $203.
If an emergency room visit leads to an admission to the hospital, the costs fall under Part A and include a $1,484 deductible and $0 coinsurance for days 1–60.
If someone has a Medigap plan, it may cover emergency visits outside the U.S. The coverage and costs of Advantage plans for emergency room visits differ from those of original Medicare.
They also vary widely among plans, so a person may wish to contact their plan provider to check coverage and out-of-pocket costs.