Does Medicare Part A Cover Emergency Room Visits?
Demystify Medicare Part A's role in emergency care. Learn how coverage works for ER visits and understand potential costs.
Medicare is a federal health insurance program that provides coverage for individuals aged 65 or older, certain younger people with specific disabilities, and individuals diagnosed with End-Stage Renal Disease (ESRD). This program is structured into different “Parts,” each designed to cover various healthcare services. Understanding these distinctions is important for navigating healthcare costs.
Understanding Medicare Part A’s Scope
Medicare Part A, often referred to as Hospital Insurance, primarily covers inpatient hospital care, including facility charges for acute care, long-term care, and critical access hospitals. Part A also covers limited stays in skilled nursing facilities following a qualifying hospital stay, hospice care, and some home health services. To qualify for Part A coverage in a skilled nursing facility, a beneficiary needs an inpatient hospital stay of at least three consecutive days. While Part A covers facility-related costs during inpatient stays, it does not cover physician fees, which fall under a different part of Medicare. Most individuals do not pay a monthly premium for Part A if they or their spouse paid Medicare taxes through employment for at least 10 years.
Emergency Room Visit Coverage
Medicare Part A covers emergency room visits only if the visit leads to a formal inpatient admission to the hospital. If a physician orders an inpatient admission, Part A covers the hospital’s facility charges, including the emergency room services that led to the admission.
A crucial distinction exists between being admitted as an “inpatient” and being under “observation status.” If a patient is held for observation, these services are considered outpatient care. In such cases, Medicare Part A does not cover the hospital facility fees, and these services fall under Medicare Part B.
The “2-midnight rule” serves as a guideline for determining inpatient versus observation status. Under this rule, an inpatient admission is appropriate for Part A coverage if the physician expects the patient’s hospital stay to cross at least two midnights. The final decision to admit a patient as an inpatient rests with the physician’s judgment and orders, based on medical necessity.
Related Services and Out-of-Pocket Costs
Physician services, diagnostic tests, and other medical services rendered in the emergency department, including those from the emergency room doctor or consulting specialists, are covered under Medicare Part B, regardless of inpatient admission or observation status. Ambulance services to the emergency room are also covered by Medicare Part B if they are medically necessary and transport by another method would endanger the patient’s health. Medicare Part B covers 80% of the Medicare-approved amount for these services after the annual deductible is met.
Beneficiaries may incur several out-of-pocket costs. For inpatient admissions covered by Part A, the Part A deductible applies per benefit period, which is $1,676 in 2025. If an inpatient stay extends beyond 60 days in a benefit period, a daily coinsurance applies: $419 per day for days 61 through 90, and $838 per day for lifetime reserve days beyond day 90 in 2025. For services covered by Part B, an annual deductible of $257 applies in 2025. After meeting the Part B deductible, beneficiaries pay 20% coinsurance for most Medicare-approved Part B services, including physician fees, observation status facility charges, and ambulance services.