Medicare and Emergency Room Coverage
As you get older, your chances of visiting the emergency room go up significantly. According to the Centers for Disease Control and Prevention (CDC), at age 65, you have a 51% chance of visiting the emergency room, a figure that jumps to 83% by the time you reach age 85.
Fortunately, Medicare generally covers you when you need emergency care. Here are answers to your top questions about Medicare coverage and the Emergency room (ER).
Is Medicare coverage available for ambulance trips to the emergency room?
CDC statistics show that about 40% of all ER visits by those 65 and over begin in an ambulance. Part B Medicare generally covers ambulance trips when transport in any other vehicle could endanger your life. If your ambulance trip to the emergency room is medically necessary, you typically pay just 20% of the allowable charges once your Part B deductible is met.
Part B Medicare coverage also may apply to air ambulance trips in an airplane or helicopter if you need emergency care faster than ground transportation can accommodate.
What Medicare coverage is available for emergency care?
In most cases, Medicare coverage protects you when you need treatment in a hospital emergency room or free-standing emergency department. Your cost are calculated a bit differently, however. When you visit the emergency room, you may pay an ER copayment plus an additional copayment for different diagnostic services such as x-rays you receive.
You’ll usually be billed separately for your doctor’s services in the emergency room. These fall under Part B Medicare coverage; you generally pay 20% of allowable charges once your deductible has been met.
If you are admitted to the same hospital for a related condition within 3 days after an emergency room visit, you typically won’t be responsible for an ER copayment amount, and your Part A Medicare coverage may pay the bill. Your Medicare Part A deductible applies and you are responsible for any applicable coinsurance amounts if your stay goes beyond 60 days.
What if I have Medicare Advantage?
If you get your Medicare coverage through a Medicare Advantage plan, you get the same emergency room coverage, at a minimum, as you would under Original Medicare. However, since Medicare Advantage plans are offered by private insurance companies approved by Medicare to provide Medicare coverage, they may pay for emergency care differently. For example, you may pay a single copayment for both the emergency room services and the doctor visit. Some Medicare Advantage plans also have an annual deductible that may or may not apply for emergency room care.
Is there Medicare coverage for emergency care outside the U.S.?
The answer is almost always no, except in very narrow cases such as travel between Alaska and another state when the closest emergency care is in Canada, for example.
If you have supplemental Medicare coverage with Medigap, your plan may pay 80% of allowable charges up to your plan limit. Not all Medicare Supplement Plans offer the foreign travel emergency benefit, so be sure to check if this is coverage you think you’ll want.
What Medicare coverage applies for prescription drugs in the ER?
Medicare coverage is typically not available for prescription medications you take at home, or any prescription drugs you receive in an outpatient setting like a hospital emergency department. If you are given medications by injection or infusion, however, Medicare Part B coverage may apply.
For example, if you normally take blood pressure medicine at a time when you are in the emergency room, and your doctor orders a dose of your medication, your medication would not typically be covered under Part B. However, if your doctor orders an injection to bring your blood pressure down while in a hospital outpatient setting, your Medicare Part B coverage generally kicks in.
If you have a Medicare Part D Prescription Drug Plan, your ER medications, including self-administered prescription drugs, are generally covered, as long as they are on your Medicare (Part D) prescription drug plan formulary.
There is generally no Medicare coverage under Medicare Part B for drugs your emergency room doctor prescribes for you to take at home, except in very specific cases, such as nausea pills used to manage side effects of chemotherapy. If you have Medicare Part D prescription drug coverage, however, your plan may cover your medications. You may have to meet your annual deductible and pay a copayment depending on your plan.
To find a Medicare Advantage or Medicare Supplement plan that may help cover emergency room visits, enter your zip code on this page.