Does Medicare Part B Cover ER Visits?

Medicare Part B, known as medical insurance, is a component of Original Medicare designed to cover various outpatient services. Medicare Part B covers emergency room (ER) visits. This article clarifies how Medicare Part B functions in an emergency setting, detailing covered services, associated costs, and hospital status distinctions.

Medicare Part B Coverage for Emergency Room Services

Medicare Part B generally covers emergency room visits for injuries, sudden illnesses, or rapidly worsening existing conditions. This includes medically necessary services provided by doctors and other healthcare professionals within the ER, such as physician services, diagnostic tests (X-rays, laboratory work, EKGs), and certain medical and surgical procedures.

Emergency services are considered outpatient care. Even if an individual spends time in the ER for observation, they are still considered an outpatient unless formally admitted as an inpatient. Medicare Part B pays 80% of the Medicare-approved amount for these services after the annual deductible is met.

Understanding Costs for Emergency Room Visits

Medicare Part B enrollees are responsible for out-of-pocket costs for emergency care. This includes an annual Part B deductible, which for 2025 is $257. After this deductible is satisfied, a 20% coinsurance applies to the Medicare-approved amount for most Part B-covered services received in the ER. Separate copayments may also apply for the ER visit itself and for specific hospital services provided.

Hospital facility charges are typically covered under Medicare Part A if the patient is formally admitted as an inpatient. If admission occurs, the Part A deductible, which is $1,676 per benefit period in 2025, would apply. Prescription drugs administered in the ER (e.g., by injection or infusion) may be covered by Part B. Self-administered medications or those prescribed for use at home are usually covered under a Medicare Part D prescription drug plan, if the individual has one, or paid out-of-pocket.

Emergency Versus Observation Status

A significant distinction in hospital care involves whether a patient is classified as an inpatient or is under observation status, as this impacts Medicare coverage and costs. Observation services are considered outpatient services, even if they involve an overnight stay in a hospital bed. When a patient is under observation, all services, including physician fees and facility charges, are covered under Medicare Part B. This means the Part B deductible and 20% coinsurance apply to each service.

Conversely, if a patient is formally admitted as an inpatient based on a doctor’s order, typically for an expected stay of two or more midnights, their hospital stay is covered by Medicare Part A. The classification as an inpatient is crucial because Medicare Part A coverage for a skilled nursing facility (SNF) stay requires a prior inpatient hospital stay of at least three consecutive days. Patients under observation status do not meet this requirement, potentially leading to significant out-of-pocket costs for subsequent SNF care. Hospitals are required to provide a Medicare Outpatient Observation Notice (MOON) if observation services last more than 24 hours, informing patients of their outpatient status and its implications.

Impact of Other Medicare Plans

Other Medicare plans can influence coverage and costs for ER visits. Medicare Advantage (Part C) plans, offered by private insurance companies, are required to cover at least the same benefits as Original Medicare (Parts A and B), including emergency services. While they must cover emergency care regardless of network, their cost-sharing structures, such as copayments or coinsurance, may differ from Original Medicare. Some Medicare Advantage plans may even have different copays for the ER visit itself and for services received within the ER.

Medigap (Medicare Supplement Insurance) policies can help cover the out-of-pocket costs associated with Original Medicare, including deductibles and coinsurance for ER visits. These policies are designed to pay for the gaps in Original Medicare coverage. For example, many Medigap plans help cover the 20% Part B coinsurance and the Part B deductible. Certain Medigap plans, like Plan N, may have specific copayments for ER visits that do not result in an inpatient admission.