Because there are a few different options when it comes to Medicare coverage, the question; does Medicare cover ER visits, has more than one answer. Each type of Medicare plan provides coverage for emergencies in a specific way.
In general, Medicare covers ER services when a beneficiary suffers from an injury or sudden illness that quickly worsens.
Original Medicare
If an individual enrolled in Original Medicare goes to the ER, they receive coverage for services from Medicare Part B. As long as they receive service from a either a hosptial or medical faciltiy that accepts Medicare. Additionally, Medicare Part B covers urgent care treatment for sudden illnesses or injuries that do not quailfy as a medical emergency.
Please note; emergency or urgent care a beneficiary receives is subject to a 20% copay as well as the annual Part B deductible. If an individual has a Medicare Supplement plan, it may cover the 20% copay.
When the beneficiary is admitted to the hosptial for a related condition within 3 days of the ER visit, they don’t pay the copay. Original Medicare processes the ER visit cost as part of the inpatient hospital stay.
Medicare Advantage
Although Medicare Advantage plans normally use provider networks for the enrollee’s care, the rules are very different during an emergency situation. When this is the case, Medicare Advantage plans must provie coverage for care even if the hospital or medical facility is out of the plan’s network. However, the copay amounts charged may differ from Original Medicare coverage. It is important to provide clients a complete picture of each plan they are considering. That includes emergency care copay amounts as well as all other coverage details and costs.
Medicare Advantage plans and the CMS consider an emergency, an untreated medical condition that could result in:
Serious jeopardy to the health of the individual. In the case of a pregnant woman, serious jeopardy to her health or the health of the unborn child. The definition also includes serious impairment or dysfunction of any organ or body part.
Some Medicare advantage plans don’t charge an ER copay if the enrollee is admitted to the hosptial within a 24 hours of the ER visit. When this happens, the MA/MAPD plan counts the ER visit as part of the hosptial stay. If the visit to the ER is later deemed not an actual emergency, MA plans cannot go back and require prior authorizatoion for the treatment.
Urgent care and Medicare Advantage plans
Instances where there is a non-emergent medical situation that requires immdiate attention, some MA/MAPD plans provide out-of-network coverage at urgent care facilities. This may happen if there is no in-network care available like on a weekend or if you are traveling outside the plan’s service area. Plan enrollees may have a copay similar to in-network urgent care.
Enrollees should check their plan’s summary of benefits or evidence of coverage for specific coverage provided by each plan. If you cannot locate these documents, enrollees can contact their insurance agent or call the member services number located on the back of their membership card.
Additional details
In general, Medicare provides coverage for ER visits that occur in the U.S.. It does not normally cover emergency medical care outside the U.S., although there are a few exeptions to this.
In some cases, Medicare supplements provide a lifetime limit of $50,000 for foreign travel emergencies. There are also Medicare Advantage plans that may provide a limited amount of coverage for foreign travel emergencies.
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