Does Medicare Cover Urgent Care Visits?
Medicare covers urgent care visits. These visits are for an unexpected injury or illness that is not serious enough to be considered a medical emergency. Medicare will pay for 80 percent of the cost of a visit. You will need to meet the Part B deductible first, then pay 20 percent of the Medicare-approved cost for all services and tests.
Medicare Coverage for Urgent Care Visits
Urgent care visits offer access to immediate medical attention for unexpected injuries or illnesses. Medicare will cover these visits and any treatment or procedures you receive during your visit under Part B.
- Bleeding from a cut
- Minor broken bones or fractures
- Urinary tract infections
- Vomiting or diarrhea
Urgent care clinics also offer other Medicare-covered services outside of immediate illness and injury. For example, you can receive annual physicals and X-rays at clinics, as well as vaccine and immunization shots.
Remember, an urgent care visit is for minor, unexpected medical conditions. Anything more serious would require a trip to the emergency room.
Medicare also covers emergency department services for these situations.
Expected Costs of Urgent Care Visits
If you have Original Medicare – Part A and B, collectively – then 80 percent of the cost for treatment and services received at an urgent care clinic will be covered.
With Part B, you will have to meet a deductible before coverage begins. After the deductible has been met, you pay 20 percent of the Medicare-approved cost.
You will also have to pay a copayment if you receive care in a hospital outpatient setting.
Urgent care visits are also covered through a Medicare Advantage plan since they include everything covered in Original Medicare.
Medicare Advantage plans also include additional benefits and coverage and what is offered in Part A and Part B.
Check with your plan provider to learn about any expanded coverage available related to urgent care trips.
As a result of your urgent care clinic, a doctor or healthcare provider may recommend a prescription drug to help you recover from your injury or illness.
Prescription drug coverage is not available through Original Medicare – but is covered by Medicare Part D as an optional benefit through private insurers.
Reimbursement for an Urgent Care Visit
As with most Part B coverage, your urgent care visit will only be covered if the clinic you visit and the doctor or healthcare provider who treats you are enrolled in Medicare.
It is important to inquire about this before you receive any services to make sure that you are covered. If not, then you will have to pay out-of-pocket for any treatment you receive.
However, you can file a Medicare reimbursement claim later to get your money back even if the clinic is not enrolled.
When filing the claim, you will need to include the bill from the doctor or clinic as well as a letter explaining your reasoning for wanting reimbursement. You can find the form to fill out here.
You must file the claim within a year of when you received the services in question.
If you have a Medicare Advantage plan, then you do not need to file a claim.
7 Cited Research Articles
- NH HealthCost. (2018, June 15). What are urgent care centers? Are they less expensive? Do I need a referral? Retrieved from https://nhhealthcost.nh.gov/guide/question/what-is-an-urgent-care-clinic
- Idaho State University (2016, June 1). Immunization and Vaccinations Available at Urgent Care Clinics. Retrieved from https://blog.cetrain.isu.edu/blog/immunization-and-vaccinations-available-at-urgent-care-clinics
- U.S. Centers for Medicare & Medicaid Services. (2015, April 10). CMS Manual System. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R206BP.pdf
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Emergency department services. Retrieved from https://www.medicare.gov/coverage/emergency-department-services
- U.S. Centers for Medicare & Medicaid Services. (n.d.). How do I file a claim? Retrieved from https://www.medicare.gov/claims-appeals/how-do-i-file-a-claim
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Urgently needed care. Retrieved from https://www.medicare.gov/coverage/urgently-needed-care
- Medicare.gov. (n.d.) Part B costs. Retrieved from https://www.medicare.gov/your-medicare-costs/part-b-costs