Does Medicare Cover Emergency Room Visits?

Medicare, a federal health insurance program, helps millions of Americans cover healthcare costs. Understanding how this coverage extends to emergency room (ER) visits is important, as these can be unexpected and costly. This article clarifies how Medicare addresses expenses related to emergency services.

Original Medicare Coverage for Emergency Services

Original Medicare comprises two main parts relevant to emergency room visits: Part A, Hospital Insurance, and Part B, Medical Insurance. Part B typically covers services received in an emergency room if a patient is not formally admitted to the hospital. This includes physician services, diagnostic tests like X-rays or blood work, and certain medical supplies provided during the ER visit. After meeting the annual Part B deductible, which is $240 in 2024, beneficiaries are generally responsible for a 20% coinsurance of the Medicare-approved amount for these outpatient services.

Part A coverage becomes active if an emergency room visit results in a formal inpatient admission to a hospital. This part of Medicare helps cover the costs of inpatient hospital stays, including room and board, nursing services, and other hospital services. For each benefit period, a Part A deductible applies; for example, in 2024, this deductible is $1,632 per benefit period. A benefit period begins the day a patient is admitted as an inpatient and ends when they have been out of the hospital for 60 consecutive days. Medicare only covers emergency services that are deemed medically necessary, meaning they are required to diagnose or treat an illness, injury, condition, disease, or its symptoms.

Medicare Advantage Plan Coverage for Emergency Services

Medicare Advantage Plans, also known as Part C, are offered by private companies approved by Medicare and operate differently from Original Medicare. By law, these plans must cover all the same emergency services as Original Medicare, providing at least the same level of benefits. However, the costs associated with emergency room visits, such as deductibles, copayments, and coinsurance, can differ significantly from Original Medicare and vary widely among plans.

Beneficiaries enrolled in a Medicare Advantage plan should review their specific plan’s Summary of Benefits or contact their plan directly to understand their exact cost-sharing details for ER visits. While Medicare Advantage plans must cover emergency care even if received out-of-network, non-emergency care may be subject to network restrictions. Choosing an in-network facility for non-urgent needs can help manage out-of-pocket expenses.

Understanding Observation Status and Inpatient Admission

A distinction affecting costs after an ER visit is whether a patient is placed under “observation status” or formally admitted as an “inpatient.” Observation status occurs when a doctor keeps a patient in the hospital to determine if formal inpatient admission is necessary or if they can be discharged. Services received during observation are considered outpatient services, even if the patient stays overnight in a hospital bed. These services are covered under Medicare Part B, and Part A coverage does not contribute to these costs.

Formal inpatient admission means a doctor has officially ordered the patient to be admitted to the hospital, typically for a stay expected to last at least two midnights. Inpatient stays fall under Medicare Part A coverage. This distinction is also important for subsequent coverage of Skilled Nursing Facility (SNF) care, as Part A SNF benefits generally require a qualifying inpatient hospital stay of at least three consecutive days.

Non-Emergency Care in the Emergency Room

While Medicare covers medically necessary services provided in an emergency room, even if the condition is not life-threatening, using the ER for non-emergencies can lead to significantly higher costs. ER fees include facility charges, physician services, and diagnostic tests, which are much more expensive than those for urgent care centers or a primary care physician’s office. An ER visit for a minor ailment could incur hundreds of dollars in out-of-pocket expenses.

For non-emergency conditions, considering alternatives can lead to cost savings and more suitable care. Urgent care centers, retail clinics, or a visit to one’s primary care doctor are often more efficient and less costly options for non-urgent medical needs. These settings handle common illnesses and minor injuries, providing a more appropriate level of care and helping beneficiaries manage their healthcare expenditures.