Medicare Part A does not usually cover emergency room visits unless a doctor admits a person to stay in the hospital as an inpatient. Medicare Part B covers outpatient emergency room visits.
This means that an insured person would need to meet their annual deductible of $198 before Medicare pays for emergency room (ER) visits. Coinsurance of 20% also applies to each visit.
In this article, we expand on which parts of Medicare pay for an ER visit and the costs a person is responsible for under Medicare.
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.
Medicare determines which portion of Medicare funds an ER visit based on the doctor’s decision to admit an insured person to the hospital as an inpatient.
Admitting a person as an inpatient means that they need further interventions and medical care before they can return home.
Around 139 million people visited an emergency room in 2017, according to the Centers for Disease Control and Prevention (CDC).
An estimated 14.5 million of those who made an emergency room visit needed hospital admission. This roughly equates to 10.4% of all emergency room visits.
If a person visits the emergency room without needing admission, Medicare Part B covers a portion of the costs. Part A pays if a person visits the ER, and a doctor admits them to the hospital.
Medicare Part A covers hospital or inpatient care.
A person usually visits the ER at a hospital. However, there is a difference between emergency care at a hospital and being a hospital inpatient.
Medicare Part A specifically covers care when a person stays as an inpatient at the hospital. Medicare considers a person an inpatient when their stay has extended beyond two midnights.
If a doctor admits a person to the hospital, the law requires that they notify the individual that they are an inpatient.
Medicare Part A covers several services, including inpatient hospital care, skilled nursing facility (SNF) care, and hospice care.
However, this part of Medicare does not cover other services that relate to an ER visit such as:
- ambulance transport
- doctor’s visits
- inpatient treatment or partial hospitalizations for mental health disorders
Medicare Part B is responsible for covering these services.
If a person has to stay at an ER overnight or for longer than 24 hours, hospital personnel should give them a Medicare Outpatient Observation Notice (MOON).
Receiving a MOON form usually means that Part B, not Part A, will cover the initial ER visit.
Medicare Part B usually covers most aspects of an individual’s visit to an ER, as long the doctor does not admit them to the hospital for reasons related to the visit.
If the doctor discharges a person from the ER to their home, they may be responsible for some or all of the following costs under Part B:
- a copayment for the emergency department visit
- a copayment for hospital services provided, such as imaging studies, medications, or lab work
- 20% of the Medicare-approved amount for a doctor’s services
- the deductible, which applies for doctor’s services
One exception to the ER coverage rules applies when a person returns to a hospital in need of inpatient care within 3 days of their initial visit to the ER.
If the hospital admits the person with the same medical condition, they do not have to pay their Part B copayment twice.
Medicare Part B also pays for ambulance and helicopter transportation when a person urgently requires moving to another location and is unable to get there without medical assistance.
The out-of-pocket expenses for emergency transportation to an ER include the 20% coinsurance. The Part B deductible applies to this amount.
If an ambulance company believes Medicare may not cover their service, they must provide an Advance Beneficiary Notice of Noncoverage.
This often applies if a person requests ambulance transport to an emergency room when their medical situation is not an emergency.
Medicare require that a Medicare Advantage plan covers the same aspects of care as Original Medicare. This means that Medicare Advantage also covers ER visits.
Medicare Advantage, or Medicare Part C, is a bundled plan that a private insurance company administers.
Medicare Advantage includes benefits from Parts A, B, and sometimes D, which covers prescription drug coverage. It may also offer coverage for services, such as vision, dental, and hearing care.
However, some types of Medicare Advantage plan require that a person chooses an in-network treatment provider when receiving emergency medical attention.
A person should review their Medicare Advantage plan so that they know their nearest in-network ER before they require emergency treatment.
Otherwise, they may have to pay more for seeking care at an out-of-network facility.
Medicare Supplement Insurance, or Medigap, is a supplemental insurance plan that a person who has Original Medicare may purchase to cover some out-of-pocket expenses, including those for Medicare Part B.
Medicare requires that Medigap plans offer the same benefits regardless of the insurance provider. A person can choose from one of several plans depending upon their healthcare needs and monthly budget.
Most Medigap plans pay for all or part of Part B’s coinsurances or copayments. This may help a person reduce the costs of an ER visit.
Medicare Part B is the Medicare portion that usually pays for ER services.
An exception applies if a doctor admits a person to the hospital, at which point Medicare Part A would pay for the visit. ER staff should inform a person whether they are an inpatient or outpatient at an emergency room.
Even if a person stays overnight for testing or observation at an emergency room, this does not necessarily mean they are an inpatient.
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