Emergencies happen. And when they do, you don’t have time to consider what your insurance covers. As you age (especially past 75) and develop medical conditions, your chance of visiting the emergency room increases. 

There are many injuries and sudden illnesses that warrant an emergency room visit. Falls, accidents, and acute concerns (like heart attacks and strokes) all require emergency medical attention. The most common reasons to visit the emergency room include:

  • Chest pain

  • Abdominal pain

  • Loss of consciousness

  • Broken bones and sprains

  • Back pain

  • Skin infections

  • Upper respiratory infections

Does Medicare cover emergency room visits?

Generally, Medicare Part B provides coverage for emergency healthcare services. Medicare Part B will also cover ambulance transportation and, in some cases, air transportation if transportation in a non-emergency vehicle will endanger your health. However, there are some stipulations. Medicare will pay for transport to the closest emergency room, so if you request another location, you may be responsible for the additional charges. 

Because Medicare Advantage must provide coverage greater than or equal to that of Original Medicare (Part A & Part B), you’re covered regardless of which path you choose for your Medicare. Your costs will be handled differently, depending on whether you have Original Medicare or Medicare Advantage.

How much does an ER visit cost with Original Medicare?

You’ll pay a copayment for each emergency department visit and a copayment for each hospital service you receive. Once you’ve met the annual Part B deductible, Medicare will cover 80% of the Medicare-approved amount for a visit. You are responsible for paying the remaining 20% out of pocket. 

If you have a Medigap plan, your coinsurance (the 20% of costs Medicare doesn’t pay) is eliminated or reduced. This makes having a Medigap plan incredibly valuable when emergencies happen.

What happens if you get admitted with Original Medicare?

If you are admitted from the emergency room to the hospital within three days of your ER visit and stay under inpatient care for two or more nights, Medicare Part A will cover your stay. In this scenario, you won’t be responsible for Part B copayments but must meet the Part A deductible of $1,600 before Medicare begins to pay. Once you’ve met your deductible, there’s no daily copayment until you’ve been hospitalized for over 60 days. 

Most Medigap plans cover all or part of your Part A deductible. They all cover 100% of your coinsurance. Once again, this makes a Medigap plan incredibly valuable for emergencies.

It is important to remember that just because you stay in the hospital for more than 24 hours does not mean you're considered an inpatient. Medicare Part B will cover your stay if the hospital admits you under observation. If you are under observation, you'll receive a Medicare Outpatient Observation Notice to explain your current status. The hospital will notify you if your status changes to inpatient. 

How does Medicare Advantage cover ER visits and hospital stays?

If you have a Medicare Advantage plan, your deductible and copay amount will vary based on your specific plan. This is why comparing deductibles, copayments, and premiums is important when selecting a plan. Sometimes, a small difference in your premium could result in much lower out-of-pocket costs. Because Medicare Advantage plans bundle Medicare Part A and Part B, the deductibles are combined. 

Medicare Advantage plans also handle inpatient care differently. They generally charge a daily copayment starting on day one of a hospital stay rather than imposing the Part A benefit period deductible. 

Emergencies are impossible to anticipate, but that doesn't mean you can't plan ahead. If you have any questions about what's included with your specific Medicare coverage, we're here to help! Chapter's Medicare Advisors can help you understand your insurance so you always know what to expect, even in an emergency.

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