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Medicare Coverage of Emergency Room

 

As many people already know, emergency room (ER) visits can be expensive. Almost 22% of Americans aged 65 and over had at least one ER visit in 2015, according to the Centers for Disease Control and Prevention (CDC), while one in 10 Americans aged 75 and over had at least two ER visits.

So, if you’re in the 65-and-over age group, your chances of an emergency room visit are something to consider. Emergency room visit costs are generally higher than a visit to your doctor, according to the U.S. Agency for Healthcare Research and Quality (AHRQ).

If you have a situation such as a heart attack, stroke, or sudden illness, Medicare Part B will cover a portion of your emergency room costs.

When Medicare covers emergency room (ER) visit costs, you typically pay:

  • A copayment for the visit itself
  • A copayment for each hospital service you receive there
  • A coinsurance amount of 20% for the Medicare-approved cost for doctor services. The Part B deductible applies.

Medicare covers emergency room services everywhere in the United States. If you are admitted to the hospital, you or your supplemental insurance must pay for the Part A deductible and coinsurance.

If you are a member of a Medicare private health plan, such as an HMO, you have a right to receive emergency care anywhere in the United States regardless of whether the hospital or provider is in the plan’s network. You do not need a referral from your primary care doctor first. Even if you receive emergency department services from an out-of-network provider, you cannot be billed more than the lesser of $50 or the in-network cost for emergency services. Your plan must also cover all medically necessary follow-up care relating to the medical emergency if delaying the care would endanger your health. If your plan does not pay for your emergency care, you have the right to appeal. 

Medicare, or your Medicare private health plan, must cover the emergency services even if your condition, which appeared to be an emergency, turned out not to be an emergency. For example, you had chest pain and thought you were having a heart attack, but at the emergency room the doctors said you just had heartburn.

Even if you do not have any health insurance, you still have the right under federal law to receive medical care in the case of an emergency regardless of your ability to pay.

Please note that if you’re admitted to the same hospital as an inpatient for a related condition within three days of your ER visit, you generally don’t pay the ER copayment, because Medicare Part A may cover the ER visit as part of your inpatient care.

Charges for an emergency room visit are usually broken out into two or more parts. There's a charge by the emergency room itself, for which Medicare Part B pays the full Medicare-approved amount, except for a patient co-payment. (This co-payment is waived if the patient is admitted to the hospital, for the same condition, within three days of the emergency room visit.)

There may also be separate charges for each specific medical service (such as X-rays or an EKG) received in the emergency room. For these services, Medicare Part B pays 80 percent of the Medicare-approved amount.

Also, a doctor who cares for a patient in the emergency room usually bills the patient separately. Medicare Part B pays 80 percent of the Medicare-approved amount for the doctor services.

Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage; the care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. 

Most ER services are considered hospital outpatient services, which are covered by Medicare Part B. They include, but are not limited to:

  • Emergency and observation services, including overnight stays in a hospital
  • Diagnostic and laboratory tests
  • X-rays and other radiology services
  • Some medically necessary surgical procedures
  • Medical supplies and equipment, like splints, crutches and casts
  • Preventive and screening services
  • Certain drugs that you wouldn't administer yourself

Medicare Part B pays for outpatient services like the ones listed above, under the Outpatient Prospective Payment System (OPPS). The OPPS pays hospitals a set amount of money (or payment rate) for the services they provide to Medicare beneficiaries. The payment rate varies from hospital to hospital based on the costs associated with providing services in that area, and are adjusted for geographic wage variations.  

NOTE: There's an important distinction to be made between inpatient and outpatient hospital statuses. Your hospital status affects how much you pay for services. Unless your doctor has written an order to admit you as an inpatient, you're an outpatient, even if you spend the night in the hospital.

Many Medicare beneficiaries purchase a Medicare Supplement or Medigap plan from a private insurance company to help pay for some or all of the Original Medicare out-of-pocket costs mentioned above. Original Medicare refers to Medicare Part A and Part B, and Medicare Supplement plans can work alongside this federal program.

Some Medicare Supplement plans (such as Plan F and Plan G) can help cover emergency medical care when you’re out of the country (80% of covered services up to plan limits). However, you will likely have to submit the bills directly to Medicare, since providers outside the USA do not participate in Medicare.

If you like your Original Medicare coverage but want to see if you can cover some of the out-of-pocket costs you’re responsible for, you may want to check out which Medicare Supplement (Medigap) plans might be available to you.  The Agents associated with this website can help with that. Schedule a phone appointment or have us email you Medigap information tailored to your needs.

 

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