There is more than one answer to the question; how are emergency room visits covered under Medicare? It all depends on the Medicare plan you have, as everyone's situation and plan to cover their needs is a little different than the next.
Original Medicare
Under Original Medicare if an individual visits the ER, they will be covered for services under Medicare Part B. (Note, the hospital or medical facility must accept Medicare.) Medicare Part B also covers urgent care visits for injuries or illness that does not qualify as a medical emergency for the ER.
It is important to note that under Original Medicare when obtaining care via urgent care or in an emergency setting the beneficiary is responsible for 20% coinsurance as well as the Part B deductible. Depending on your plan type, you may receive coverage for the deductible and or coinsurance. If the individual is admitted to the hospital within three days for a related condition to the ER visit, the coinsurance will be waived as the service will be processed under Original Medicare as an inpatient hospital stay.
Medicare Advantage
Medicare Advantage plans function on networks of providers, but in the case of an emergency for the beneficiary it can function quite differently. In this case, the plan must provide coverage for the beneficiary regardless of whether or not the hospital or provider is out-of-network. On top of that, the copay amounts can differ greatly than that of what is charged under Original Medicare. It is very important to cover all of the details regarding coverage and payments when reviewing plans with your clients.
Some MA plans do not charge for ER visits when the beneficiary is admitted to the hospital within 24 hours of visiting the ER, the ER visit is included as part of the inpatient hospital stay. If it is later deemed that the ER was not an actual emergency, the plan cannot back track and require prior authorization for treatment.
Urgent Care & MAPD Plans
Some MAPD plans do infact provide non-emergency urgent care for out-of-network facilities, this can come in the form of similar copays as in-network facilities.
