Does Medicare Cover ER Visits?
Medicare covers emergency room visits, but how much you pay depends on your patient hospital status. If you visit the ER but aren’t formally admitted to the hospital, you are considered an outpatient under Medicare Part B. If you are admitted, you are considered an inpatient under Medicare Part A.
Emergency Room Visits and Original Medicare Costs
Your hospital status — whether you’ve been formally admitted to a hospital — affects how much you pay for emergency care and what part of Medicare applies.
When you visit a hospital’s emergency department, via either an ambulance or the waiting room, you’re initially considered an outpatient. You may be considered an outpatient even if you stay overnight in the hospital.
Outpatient emergency room visits are covered by Medicare Part B.
- You usually pay 20 percent of the Medicare-approved cost for doctor and other health care provider's services.
- You’ll also usually face a copayment from the hospital for each Medicare-covered service you receive, such as X-rays or lab tests. Copays typically can’t exceed the $1,484 Part A deductible for each service.
- The Part B deductible — $203 in 2021 — also applies. You may not owe this if you’ve already met your yearly deductible before arriving at the hospital.
This can be confusing. If you’re in the emergency room, how can you be an outpatient?
Medicare only provides hospital inpatient coverage after a doctor writes an order and formally admits you to the hospital.
Typically, inpatient admission takes place when you’re expected to need at least two nights of medically necessary hospital care.
If you are admitted to the hospital, Medicare Part A covers your entire stay. Your trip will be considered an inpatient stay and ER-related copays won’t apply.
- Your $1,408 Part A deductible applies for each benefit period.
- You will owe a $0 coinsurance payment for your first 60 days in the hospital.
Admission must take place at the hospital where ER services were provided. Getting admitted to a different hospital within three days, even for the same condition, is considered a separate event.
Examples of How Original Medicare Covers ER Visits
Let’s say you arrive at the ER with severe ear pain. You wait in the lobby and after you are called back, hospital staff run tests, write you a prescription for antibiotics, write you a referral for follow-up care outside the hospital and send you on your way.
This would be considered an outpatient visit because you never left the emergency department and a doctor never formally admitted you to the hospital. Your visit would be covered under Medicare Part B.
Now, let’s imagine you arrive at the ER because you are experiencing chest pain. After running tests, hospital staff learn that you suffered a heart attack. They hold you for observation before determining that you need more extensive care.
A doctor then writes an order to formally admit you to the hospital about 24 hours after you arrived at the ER.
Your entire visit, even the 24 hours you technically spent as an outpatient under observation in the ER, is now covered under Medicare Part A.
The way Medicare classifies your stay — either as an inpatient or outpatient — directly impacts your bill.
Make sure to ask the doctor or a hospital social worker if you’re an inpatient or outpatient to avoid surprises.
Coverage and Costs of ER Visits with Medicare Advantage
Medicare Advantage plans serve as an alternative to Original Medicare.
These plans are administered by private insurance companies and often bundle benefits from Medicare Part A and Part B with Part D prescription drug coverage.
Medicare Advantage plans cover ER visits — along with everything else covered by Original Medicare.
Medicare Advantage covers ER visits anywhere in the U.S., and you aren’t required to use in-network hospitals for emergency care.
However, each Medicare Advantage plan sets its own cost terms for ER visits. These costs can differ from Original Medicare.
For example, a Medicare Advantage plan may require you to pay a copayment per visit that accounts for both the emergency room and the doctor. Or it may charge a flat fee per visit plus coinsurance for each service you receive in the ER.
Examples of How ER Costs Vary Among Medicare Advantage Plans
The way a Medicare Advantage plan bills you for a trip to the ER — and how much you owe — can vary from plan to plan.
For example, the Medicare Advantage PPO Plus Plan by Anthem Blue Cross charges beneficiaries $250 for admission to emergency room facilities plus a 20 percent coinsurance payment for services. It also charges a flat $100 rate for doctor services in the ER plus a 20 percent coinsurance payment.
Meanwhile, the Cigna‑HealthSpring Advantage HMO plan offers beneficiaries a flat $90 copayment for Medicare‑covered emergency room visits. If you’re admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit with this plan. A deductible may or may not apply.
These are just two examples of how emergency room costs can differ among Medicare Advantage plans.
There are thousands of different Medicare Advantage plans across the country, so it’s important to check with your specific provider to learn how much a trip to the ER may cost you.
4 Cited Research Articles
- Gabayan, G., Liang, L., Doyle, B., et al. (2018, July 7). Emergency Department Increased use of Observation Care for Elderly Medicare Patients. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935261/
- Medicare.gov. (n.d.). Inpatient hospital care. Retrieved from https://www.medicare.gov/coverage/inpatient-hospital-care
- Medicare.gov. (n.d.). Inpatient or outpatient hospital status affects your costs. Retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/inpatient-or-outpatient-hospital-status
- Medicare.gov. (n.d.). Outpatient hospital services. Retrieved from https://www.medicare.gov/coverage/outpatient-hospital-services