Does Medicare Cover Emergency Room Visits?

Medicare is a federal health insurance program designed to provide coverage for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease. Emergency room visits can be a significant concern for beneficiaries, as understanding coverage can be complex.

How Medicare Covers Emergency Room Visits

Medicare’s coverage for emergency room visits largely depends on whether a patient is formally admitted to the hospital as an inpatient or remains under outpatient status. This distinction is crucial for determining which part of Medicare covers the services and how costs are applied.

Medicare Part A covers inpatient hospital care. If an emergency room visit leads to a formal inpatient admission, Part A covers the hospital services, including emergency room charges as part of that admission. If a patient is admitted within three days of an emergency room visit for a related condition, the emergency room visit may be considered part of the inpatient stay and covered by Part A.

Medicare Part B covers most emergency room visits where the patient is not formally admitted as an inpatient. This includes doctor’s services, diagnostic tests such as X-rays and lab work, and other services received in the emergency room while under outpatient care. This outpatient status applies even if the patient spends the night in the hospital for observation. Observation services are considered outpatient services, despite potentially involving an overnight stay, as they are for monitoring a patient’s condition to decide whether admission is necessary.

Understanding Your Costs for Emergency Room Care

The financial responsibility for emergency room care under Medicare varies significantly based on a patient’s status and the specific services received. Understanding these costs involves knowing how deductibles, coinsurance, and copayments apply.

For services covered under Medicare Part B, which includes most outpatient emergency room care, beneficiaries must first meet an annual deductible. In 2024, this annual Part B deductible is $240, increasing to $257 in 2025. After meeting this deductible, beneficiaries pay 20% of the Medicare-approved amount for most Part B-covered services. This 20% coinsurance applies to physician fees and outpatient emergency room services.

If an emergency room visit results in a formal inpatient admission, Medicare Part A costs come into play. A Part A deductible applies per benefit period. For 2024, the Part A deductible is $1,632, and for 2025, it is $1,676. A benefit period begins the day a patient enters a hospital and ends when they have been out of the hospital or a skilled nursing facility for 60 consecutive days. For inpatient stays lasting beyond 60 days in a benefit period, daily coinsurance amounts apply.

When a patient is under observation status, even if it involves an overnight stay, they are considered an outpatient, and Part B rules apply. This means the Part B deductible and 20% coinsurance for both facility and physician services will be the patient’s responsibility. This can sometimes result in higher out-of-pocket costs compared to an inpatient admission, particularly because medications received in observation are often covered under Part B, not Part A, and may incur additional charges. Medicare Advantage Plans (Part C) must cover emergency services, but their specific copayments, deductibles, and coinsurance amounts may differ from Original Medicare.

Specific Situations Affecting Emergency Room Coverage

Certain circumstances can influence how Medicare covers emergency room visits, extending beyond the standard inpatient or outpatient distinctions. These situations involve specific types of services or particular plan structures.

Medicare Part B covers medically necessary ambulance transportation to an emergency room. For coverage, the ambulance must be the only safe means of transportation, or the patient’s health would be jeopardized by other transport methods. Medicare covers transport to the nearest appropriate medical facility that can provide the necessary care.

Using the emergency room for conditions that are not true emergencies may affect coverage. If an emergency room visit is deemed not medically necessary for an emergency condition, but could have been handled in a doctor’s office, it might lead to different coverage or higher costs, as Medicare only covers medically necessary services.

For individuals with Medicare Advantage plans, emergency care must be covered even if the emergency room is considered out-of-network. However, while emergency services are covered, follow-up care for conditions treated in an out-of-network emergency room might require transitioning to in-network providers to ensure continued coverage and avoid higher costs. Excluded services include:
Cosmetic procedures
Routine eye exams
Most dental care
Hearing aids
Long-term care that is not medically necessary

Navigating an Emergency Room Visit with Medicare

Understanding practical steps can help Medicare beneficiaries manage an emergency room visit effectively. Being prepared with information and knowing what questions to ask can assist in navigating the process and understanding financial implications.

When arriving at an emergency room, it is helpful to have your Medicare card or its information readily available. Providing this information at registration helps the facility process your care under your Medicare benefits.

It is important to inquire about your status while receiving care, asking if you are being admitted as an inpatient or placed on observation status. This distinction significantly affects your out-of-pocket costs and subsequent coverage for services like skilled nursing facility care. If you are on observation status for more than 24 hours, the hospital is required to provide you with a Medicare Outpatient Observation Notice (MOON). The MOON explains that you are an outpatient, not an inpatient, and details the implications of this status regarding Medicare cost-sharing and coverage.

After your visit, you will receive an Explanation of Benefits (EOB) from your Medicare Advantage or Part D plan, or a Medicare Summary Notice (MSN) if you have Original Medicare. These documents are not bills but provide a summary of the services you received, what Medicare paid, and your financial responsibility. Reviewing these notices carefully is important to ensure accuracy and understand how your benefits were applied. If you have questions or concerns about your bill or the services listed, contacting Medicare directly or your Medicare Advantage plan is advisable for clarification and assistance.