Does Medicare Part A Cover Emergency Room Visits?

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  • Does Medicare Part A cover emergency room visits? Find out how your Medicare benefits can protect you in case of an injury or sudden bout with illness.

Does Medicare Part A Cover Emergency Room Visits?

Medicare Part A does not automatically pay for visits to the emergency room, though your stay in the hospital might fall under the Part A inpatient benefit. For billing purposes, most trips to the emergency department are considered outpatient treatment. This is true even if you are kept overnight in the ER for observation. Under some circumstances, however, Medicare Part A will pay for your time in the emergency room, provided you are admitted to the hospital on the same visit.

The Parts of Medicare

Medicare is the federal health insurance program for older adults in the United States. Tens of millions of American seniors use some form of Medicare benefits to pay for their health needs, though the program’s organization can get confusing. Original Medicare pays for benefits through three basic programs, called parts.

What Does Medicare Part A Cover?

Medicare Part A is the basic inpatient benefit. Part A pays most of the cost of your time in the main hospital, whether you checked in on your own or were admitted through the ER, as well as for inpatient care in a residential facility. Medicare Part A also pays for most of the treatments you get while staying in the hospital as an inpatient.

What Does Medicare Part B Cover?

Medicare Part B is the outpatient benefit. Almost every service, treatment, product or other medical expense aside from prescription drugs falls under Part B for payment. Your ride to the hospital in an ambulance is usually considered outpatient care for billing purposes, as is a brief visit to the emergency department. Even a short stay in the main hospital might be billed as an outpatient expense if it lasts less than 24 to 48 hours.

What Does Medicare Part D Cover?

Medicare Part D is the prescription drug benefit. This program helps pay the cost of the medications you pick up from the pharmacy. Drugs administered in the ER are not typically covered by Part D, nor are medications given to inpatients, such as surgical anesthesia, which would usually fall under Part A.

Medicare does have a Part C, which is a shorthand name for Medicare Advantage. Medicare Advantage plans are offered by private health insurance companies and combine all of the benefits of Medicare Parts A and B, plus some extra benefits for one monthly premium, which might be $0. If you have a Medicare Advantage plan, check with your provider to find out how visits to the emergency room are covered.

What Medicare Covers

Whether you use Original Medicare or Medicare Advantage, your basic coverage is close to complete. Inpatient services, outpatient treatments and durable medical supplies are all paid for by Medicare in one form or another, as are prescriptions and some transportation costs via ambulance. Medicare generally does not pay for vision or dental care, though some Medicare Advantage plans include these as extras for their members. Many Medicare beneficiaries also use a supplemental insurance policy, often called Medigap, to cover any gaps in care. If you have limited income or assets, or you have a medical need for coverage, you could also qualify for Medicaid as a gap coverage option. Medicaid generally does pay for emergency room visits, though your Medicare coverage is always billed first.

When Does Medicare Part A Cover Visits to the Emergency Room?

Medicare Part A will sometimes pay for a trip to the emergency room, though only if you are admitted to the hospital as a result of your visit. To be considered eligible for Part A remittance, your visit to the emergency room must lead to admission to the main hospital for two consecutive days, measured as midnight to midnight. If you are discharged before the second midnight is reached, your Part A is not likely to pay for what Medicare considers an outpatient treatment. Check your MOST form, which should be available before you leave the ER, to see how your services are being billed.

Using Medicare to Pay for Your ER Visit

If you plan to use your Medicare benefits to pay for your visit to the emergency room, you do not need to know all of the details of how the trip is billed. Most people who get Part A coverage have also enrolled in Medicare Part B, which can both be billed from the same Medicare ID number on your membership card. If you have a qualified Medicare Advantage plan, which combines Parts A and B into a single policy, simply present your card at the point of payment. You are still required to pay any deductible or unmet share of cost, but the billing department at the hospital can generally handle the billing for you.

If you have supplemental coverage through a third party, including Medicaid, present your membership card for that policy at the same time you provide your Medicare billing information. In most cases, the hospital bills Medicare first, either Part A or B, and then it dips into your supplemental coverage to pay for the remaining unpaid balance. If you still have a deductible, you can usually pay with a debit or credit card. If you do participate in Medicaid, even as a supplement to Medicare, you should know that providers are not allowed to charge you for services. Call your Medicaid caseworker if you receive a bill after a Medicaid-covered treatment.

Other Resources That Can Help Pay for Emergency Care

Medicare Parts A, B and C are very popular ways to help seniors pay the cost of hospitalizations and ER visits. These are not your only options, however. If you are a Medicare participant who either does not have Part B coverage or you have a share of cost to cover before your benefits kick in, you do have options to help cover the cost.

Medicaid

If you have Medicaid, your trip to the emergency room is very likely to be covered, provided a doctor signs off that it was medically necessary. Many private health insurance plans have a similar requirement for payment to be made.

Injuries on the Job

If your trip to the emergency department is a result of a work injury, your employer is likely to pay for the cost of your trip. Workers’ compensation rules require employers in most cases to send you for immediate medical evaluation if you have been injured as their employee, and your treatment in the emergency department is potentially covered by the employer’s insurance.

Hospital Programs for People With Limited Means

If you are not employed, or if you have limited benefits to pay for your trip to the emergency department, tell the charge nurse at your earliest opportunity. Many hospitals have special pricing and programs for people with limited means to pay. This is especially likely at county, university and teaching hospitals.