Will Medicare Pay for Me to Go to ER vs Urgent Care?
Summary: Urgent care is for non-life threatening conditions that you can’t wait to see your primary care provider for. The emergency room (ER) is for possible life-threatening conditions that need immediate attention. Medicare generally may pay for both.
In most parts of the country, if you’re not feeling well, you have several choices for care. If your doctor is closed or can’t squeeze you in right away, an urgent care clinic might be open. If you’re really ill, an emergency room is there to take care of you. But if you’re on Medicare, you may wonder whether to go to urgent care vs ER, and what your choice means for your Medicare costs.
When should I go to urgent care vs ER?
Let’s start by explaining the difference between the two. An urgent care center is a walk-in facility, usually staffed by doctors or physician’s assistants and nurses. They often have access to lab and x-ray equipment to help diagnose conditions such as fractures and infections. They are designed to treat less serious, non-life threatening conditions according to the Cleveland Clinic:
- Minor injuries such as sprains, strains, lacerations and mild burns
- Infections such as sinusitis, ear infection, upper respiratory infection, strep throat, ear infection, conjunctivitis
- Low-grade fever, nausea, vomiting, and diarrhea
One of the main differences of urgent care vs ER is that emergency rooms are designed to treat more serious, life-threatening illnesses and injuries. Emergency rooms are usually attached to a hospital, which means they have access to advanced medical equipment and medical specialists. You should visit an emergency room according to the Cleveland Clinic for situations such as:
- Chest pains, trouble breathing, heart attack symptoms
- Loss of consciousness, dizziness, fainting, or seizures
- Stroke symptoms such as sudden inability to speak, sudden severe headache, paralysis or weakness
- Head injuries
- Serious injuries such as broken bones, deep lacerations with heavy bleeding, or serious burns
- Poisoning or overdose
- High fever, coughing or vomiting blood, severe vomiting or diarrhea
- Suicidal thoughts
If you’re not sure whether urgent care vs ER is more appropriate for your situation, and you have a Medicare Advantage plan, you may be able to call your nurse hotline for advice.
What are my Medicare costs for urgent care vs ER?
If you have Original Medicare (Part A and Part B), your Medicare costs for urgent care are covered by Part B. After you meet your Part B deductible, you pay 20% of allowable charges for your urgent care visit. If you have lab work, x-rays, or other tests, you may get several bills in addition to the bill from the urgent care center. All of these bills are typically covered by Part B, so your Medicare costs would be 20% of the allowable charge for each service you receive while you’re at the urgent care center.
If you have a Medicare Advantage plan, your Medicare costs depend on your plan cost-sharing. Many Medicare Advantage plans charge a flat copayment for each urgent care visit, regardless of the services you receive. You may or may not have an annual deductible with Medicare Advantage.
If you go to the emergency room, Part B also pays for your care. However, in addition to your 20% coinsurance for any services you receive, your Medicare costs include a copayment for each visit. However, if you are admitted to the same hospital for a related condition within three days of your ER visit, you won’t have to pay the copayment, because Medicare treats it as part of your inpatient stay. Medicare costs for inpatient care are covered by Part A. You pay a deductible for each benefit period, but there is typically no coinsurance unless your stay exceeds 60 days.
With Medicare Advantage plans, your urgent care vs ER costs also depend on the plan. Many plans charge a flat copayment for ER visits; this fee is often waived if you are admitted.
What are my Medicare costs for prescription drugs I get at urgent care vs ER?
If you have Original Medicare, Part B may pay for any prescription drugs administered by a medical professional while you are a patient. If you get a shot or an IV infusion, Part B pays 80% after you meet your deductible. It may also cover certain oral medications given in the urgent care or ER.
If your doctor prescribes medications for you to take at home, Original Medicare typically doesn’t cover them. However, if you have Part D coverage for prescription drugs, your plan usually covers your medications. Check your formulary (list of covered medications) for coverage details.
If you have a Medicare Advantage plan, your prescription drugs are usually covered while you are a patient. Since most Medicare Advantage plans include Part D prescription drug coverage, your take-home prescriptions will also likely be covered. Again, you should check your plan formulary for specifics.
To look for a Medicare Advantage plan that covers Urgent Care and ER, enter your zip code on this page.