Does Medicare Cover Emergency Room Visits?
Navigate Medicare's coverage for emergency room visits. Discover what's included and your potential out-of-pocket costs.
Understanding Medicare coverage for emergency room (ER) visits is important for beneficiaries. Medical emergencies can arise at any time, making it crucial to know how healthcare expenses are managed. Knowing the scope of coverage helps individuals make informed decisions during stressful health situations and clarifies the financial aspects of seeking emergency medical attention under Medicare.
Medicare’s Basic Coverage for Emergency Room Services
Original Medicare, composed of Part A (Hospital Insurance) and Part B (Medical Insurance), provides coverage for emergency room services. Medicare Part A generally covers facility costs if an individual is formally admitted to the hospital as an inpatient following an ER visit. This includes expenses such as nursing services, the use of the ER, supplies, and diagnostic tests performed within the emergency department during an inpatient stay. If the ER visit leads to an inpatient admission for a related condition within three days at the same hospital, the ER services may be considered part of the inpatient stay, and Part A coverage would apply.
Medicare Part B covers emergency department services when an individual experiences an injury, a sudden illness, or an illness that rapidly worsens. This includes professional services rendered by physicians and other healthcare providers in the ER, as well as diagnostic tests and other outpatient services received. If an individual is treated and released from the ER without being formally admitted as an inpatient, or if they are under observation status, Medicare Part B covers the visit.
Medicare Part B also covers medically necessary ambulance transportation to the nearest appropriate medical facility. This applies to both ground and air ambulance services when transportation by ground ambulance is not medically appropriate.
Understanding Out-of-Pocket Costs for Emergency Room Care
Beneficiaries under Original Medicare face specific financial responsibilities for emergency room care. Medicare Part B covers 80% of the Medicare-approved amount for most services after the annual Part B deductible is met. This means individuals are responsible for the remaining 20% coinsurance for physician services and other Part B-covered outpatient services received in the ER. The Part B deductible, which is $257 in 2025, must be satisfied before Medicare begins to pay its share. In addition to the Part B coinsurance for professional services, individuals typically pay a separate copayment for the hospital outpatient facility services received during an ER visit.
If an ER visit results in a formal inpatient hospital admission, the Part A deductible applies to the hospital stay. For 2025, the Part A deductible is $1,676 per benefit period.
Emergency Room Coverage with Medicare Advantage Plans
Medicare Advantage (Part C) plans are provided by private insurance companies approved by Medicare and offer an alternative way to receive Medicare benefits. By law, these plans are required to cover all services that Original Medicare covers, including emergency services, even if the emergency room is out-of-network. This means Medicare Advantage plans cannot require prior authorization for true emergencies.
While Medicare Advantage plans must cover emergency care regardless of network, the specific cost-sharing can vary significantly between plans. Beneficiaries typically pay a set copayment per ER visit, which can differ from the coinsurance structure of Original Medicare. For instance, some plans may have a copayment of approximately $135 for each ER visit.
Medicare Advantage plans differentiate between emergency care and urgent care. Urgent care is for less severe illnesses or injuries that require prompt attention but are not life-threatening. While emergency care is covered out-of-network, non-emergency follow-up care or other routine services may require using in-network providers to avoid higher out-of-pocket costs. Plans usually have specific rules regarding their provider networks, though emergency services are an exception to these network limitations.
Navigating an Emergency Room Visit with Medicare
When heading to the emergency room, it is advisable for Medicare beneficiaries to bring their Medicare card or Medicare Advantage plan identification card. It is also helpful to have a list of current medications and any known allergies readily available.
After an ER visit, individuals will typically receive an Explanation of Benefits (EOB) from Medicare or a statement from their Medicare Advantage plan. This document details the services received, the amount Medicare paid, and the amount the beneficiary is responsible for. Understanding the EOB can help clarify the charges incurred.
Should questions or discrepancies arise regarding a bill, individuals can contact the hospital’s billing department for clarification. For issues related to Medicare coverage or billing, beneficiaries can reach out to their Medicare Advantage plan directly or contact Medicare for assistance. If formally admitted to the hospital after an ER visit, it is important to confirm inpatient versus outpatient status, as this impacts Medicare coverage and costs.