You never know when a medical emergencyWhen you believe you have an injury or illness that requires immediate medical attention to prevent a disability or death. will happen. When it does, getting immediate treatment at the nearest emergency room is the best course of action. However, once the danger has passed, you might have another emergency on your hands, the emergency room bill.
In this MedicareWireMedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. article, we’ll help you gain a better understanding of exactly how Medicare covers emergency room visits.
Key Takeaways
- Emergency rooms are used for the immediate treatment of a condition that could cause permanent disability or death, such as a heart attack.
- After the emergency room has provided its service, the patient will either be admitted into hospital services or be discharged with recommended outpatient services.
- Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. provides coverage for emergency room visits.
- Medicare will typically not cover costs for foreign emergency rooms except in specific circumstances.
- Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will cover emergency room visits, but your out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. may vary.
- MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. will help with out-of-pocket costs for emergency rooms after Part B has provided its coverage.
- Certain Medigap plans will help with emergency care while outside of the United States.
When Should Someone Visit the Emergency Room?
An emergency room (ER) visit is necessary if someone is experiencing an emergency medical condition that requires immediate treatment to prevent a disability or death. Examples of emergency medical conditions that warrant a visit to the ER include:1Mayoclinic.org, “Emergency Medicine: Services“, Accessed December 9, 2021
- Difficulty breathing
- Pressure or pain in the chest
- Severe infections, including sepsis cases
- Acute abdominal pain
- Heavy bleeding
- Persistent or high fevers (103 F /39.4 C)
- Unconsciousness
- Fractures
- Motor vehicle collision injuries
- Head or neck injuries
- Sudden severe headaches, paralysis, seizure, or stroke symptoms
- Dehydration
Once a person’s emergency condition has been determined and/or treated, their health care providerA person or organization that’s licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers. will either discharge them or admit them into hospital care. If they are discharged from the ER, they will be provided with instructions for further treatments and services.2Mayoclinic.org, “Emergency Medicine: Emergency treatment at Mayo Clinic“, Accessed December 9, 2021
When Does Medicare Cover An Emergency Room Visit?
In most cases, Medicare Part B covers hospital emergency room (ER) services due to an injury, a sudden illness, or an illness that quickly worsens. If you have Part B and you go to the ER:3Medicare.gov, “Emergency department services“, Accessed December 9, 2021
- You pay a copayment for each ER visit and a copayment for every service the hospital provides; and
- You will pay a 20 percent coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. for the Medicare-approved amountA Medicare-approved amount is what Medicare will pay for a covered service. Healthcare providers that agree to Medicare assignment accept the approved amount without excess charges. What Does Medicare-Approved Amount Mean? A Medicare-approved amount is... of your doctor’s services (annual Part B deductible applies).
If your doctor determines you need to be admitted to inpatient care at the hospital, you will not be billed for the ER copayment for the first three days you were in the ER.3Medicare.gov, “Emergency department services“, Accessed December 9, 2021
Medicare and Foreign Travel Emergencies
Medicare rarely covers emergency services in foreign countries. With that said, Medicare may pay for inpatient hospital, doctor, and ambulance services you get in a foreign country in these rare cases:4Medicare.gov, “Travel“, Accessed December 9, 2021
- You’re in the U.S. when a medical emergency occurs that requires immediate medical attention to prevent a disability or death, and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition.
- You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency.
- You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists.
In some cases, Medicare may cover medically necessary health care services you get on board a ship within the territorial waters adjoining the land areas of the U.S. Medicare won’t pay for health care services you get when a ship is more than 6 hours away from a U.S. port.4Medicare.gov, “Travel“, Accessed December 9, 2021
Medicare Advantage Emergency Room Coverage
If you have a Medicare Advantage plan, your plan must cover ER visits, same as Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Part B. Since this would be considered an emergency treatment, you are not restricted to in-networkDoctors, hospitals, pharmacies, and other healthcare providers that agree to health plan members' services and supplies at a set price are in-network providers. With some health plans, your care is only covered if you get... providers until your immediate emergency condition has been treated. However, your out-of-pocket costs may be different than outlined above in “When Does Medicare Cover An Emergency Room Visit?”. Check with your Medicare Advantage plan provider for details.5Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 9, 2021
Medigap
If you have Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. (Part A and Part B), you can purchase a Medicare supplement insurance policy (Medigap) to help cover out-of-pocket costs. This includes any out-of-pocket costs you have remaining after your visit to the ER, such as:6Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed December 9, 2021
- DeductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.
- Coinsurance
- CopaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.
- Blood
Medigap and Foreign Travel
While Medicare rarely covers emergency services in foreign countries, the standard Medigap Plans C, D, F, G, M, and N have a lifetime limit of $50,000 for foreign travel emergency coverage when traveling abroad. Medigap Plans E, H, I, and J also have foreign travel emergency coverage, but these are currently not for sale. With that said, if you bought one of those plans before June 2010, you still get to use it without issue.7Medicare.gov, “Medigap & Travel“, Accessed December 9, 2021
If you have one of the Medigap plans listed above, your plan:7Medicare.gov, “Medigap & Travel“, Accessed December 9, 2021
- Covers foreign travel emergency care if it begins during the first 60 days of your trip and if Medicare doesn’t otherwise cover the care.
- Pays 80 percent of the billed charges for certain medically necessary emergency care outside the U.S. after you meet a $250 deductible for the year.
Summary
You should now have a better understanding of how Medicare covers an emergency room visit. Medicare Part B will provide coverage for the emergency room and you will have a remaining 20 percent coinsurance, as well as a copayment unless you are admitted to the hospital.
If you plan on traveling outside of the United States, it would be a good idea to talk with your Medigap plan provider first, if you have one. They will go over any details about your Medigap plan concerning foreign travel.
If you are concerned about how Medicare covers your ambulance transportation to the emergency room, please read our MedicareWire article on the topic here.
Citations
- 1Mayoclinic.org, “Emergency Medicine: Services“, Accessed December 9, 2021
- 2Mayoclinic.org, “Emergency Medicine: Emergency treatment at Mayo Clinic“, Accessed December 9, 2021
- 3Medicare.gov, “Emergency department services“, Accessed December 9, 2021
- 4Medicare.gov, “Travel“, Accessed December 9, 2021
- 5Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 9, 2021
- 6Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed December 9, 2021
- 7Medicare.gov, “Medigap & Travel“, Accessed December 9, 2021