Medicare Urgent Care Coverage

Urgent care has emerged in the last few decades as an increasingly popular choice for people to get medical attention. Roughly 89 million people in the United States paid a visit to an urgent care center in 2019, and the number has been steadily going up every year.

At the same time, Medicare enrollment has increased with the aging baby boom generation, with more than 62 million older adults participating in the program in 2020. Many Medicare enrollees have questions about their coverage limits for quickly being seen by a doctor, specifically whether Medicare offers urgent care coverage for its members.

Common Types of Medical Visits

Urgent care is one of the four main routes to seeing a doctor in the United States. People having elective surgery can check themselves into an inpatient hospital for their scheduled procedure, and individuals who need routine medical care often set an appointment with their doctor at an outpatient clinic or medical office. Sudden, life-threatening injuries and illnesses can be treated in the emergency department at many hospitals. Urgent care is a hybrid form of care that combines many of the most helpful features of these other types of medical visits.

What’s the Difference Between Urgent Care and the Emergency Department?

People who visit an urgent care center generally don’t need an appointment and are likely to see a doctor within a few minutes or hours of arrival. This is similar to the way most emergency departments work, but there are several important differences.

Emergency Room Care

Emergency rooms, for example, deal with a very wide and unpredictable variety of health emergencies, and so they have to be staffed and equipped for almost anything that can injure a person or make someone sick. This is expensive, and so a visit to the ER typically costs thousands or even tens of thousands of dollars.

Urgent Care

Urgent care services are mostly for people who need to get seen right away, but whose conditions aren't immediately life-threatening. Because of this, a typical urgent care office doesn’t need most of the expensive equipment and trauma specialists available in an emergency department. This helps keep costs down, though urgent care is more expensive than scheduled medical office visits.

Can People With Medicare Get Urgent Care?

Medicare covers essential medical services, including urgent care visits on both a scheduled and walk-in basis. If you have Original Medicare, your Part B component is likely to cover your urgent care visit at the usual outpatient rates. In 2021, your likely out-of-pocket cost is 20% of the cost of the visit, plus your $203 annual deductible, if you haven’t already paid it for other services.

If you can, it is a good idea to check ahead of time to make sure your urgent care provider is authorized to bill Medicare for your services. Original Medicare can only pay 80% of the Medicare-approved price for a visit, which may be different from the price the urgent care clinic charges non-Medicare visitors.

If you get your benefits through Medicare Advantage, sometimes known as Medicare Part C, you have all of the same benefits as you would for Original Medicare Parts A and B. Many Medicare Advantage plans, which are issued through private insurance companies, include additional coverage that Original Medicare doesn’t offer. Some Part C plans may pay more than the 80% of your visit cost that Original Medicare pays, and your policy might even waive the standard Part B deductible for urgent care. Speak with a representative of your Medicare Advantage issuer to find out what your coverage includes.

Handling Out-of-Pocket Costs Under Medicare

If you charge your urgent care visit to Medicare, you may be responsible for any costs Part B doesn’t cover. For a visit that could cost several hundred or a few thousand dollars, even the unpaid 20% share of cost can add up for you. Many Medicare beneficiaries choose to carry a Medicare supplemental policy that can help pay the difference between your Medicare benefits and the maximum out-of-pocket costs you’re expected to pay yourself. With a comprehensive Medicare supplement, you might not owe any money for your visit, or you may have to pay a reduced amount. Speak with a plan rep from your supplemental policy issuer for specifics about paying for urgent care.

Some Medicare beneficiaries also qualify for Medicaid. If you meet your state’s Medicaid income and asset limits, you might owe little or no money for the cost of the urgent care you received during your visit. The cost of care for dual-eligible Medicare participants goes first to Medicare’s Part B component, and then the remaining costs are billed to your Medicaid policy.

Each state operates its own Medicaid system, and each has its own set of rules, coverage limits and eligibility criteria. A Medicaid intake worker can probably give you a clear picture of what your likely costs are if you need urgent care. Be aware that not all urgent care clinics accept Medicaid benefits for payment. If the center you visit doesn’t take your Medicaid card, you could be billed for the 20% coinsurance left by the standard Part B coverage.

Where to Get Medicare Urgent Care

Urgent care is an increasingly popular choice for people who need to get seen without an appointment, but whose medical condition doesn’t rise to the level of an emergency. Because of its growing demand, urgent care is available in just about every city in the United States, and many plan and independent providers offer it.

If you are enrolled in an HMO or PPO style network for healthcare, your first choice for urgent care should be at a plan provider’s office. Many provider networks offer urgent care at member clinics that operate apart from the inpatient facilities in the network, while some provide urgent care services from the same medical office buildings where your regular physician works. It's a good idea to know beforehand where your nearest urgent care center is located.

Independent urgent care clinics are common in many places. Almost all of them accept walk-ins, though there might be a wait to see a doctor. If you have the symptoms of a serious illness, or you think you’ve suffered a serious injury, it's important to seek medical attention without delay. If you think your injury or illness puts you at risk of serious further harm, go to the emergency room right away. If your condition is less threatening, go to an urgent care center as soon as you reasonably can. You do not need preapproval from Medicare to get emergency or urgent care when you’re sick.