How does Medicare cover emergency room costs?

A different definition of emergencies. For Advantage plans, the Centers for Medicare & Medicaid Services (CMS) considers an emergency medical condition one that, if not treated, could result in:

• Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child. ​​

• Serious impairment to bodily functions.

• Serious dysfunction of any bodily organ or part.

Your emergency medical condition status is not affected if a later medical review found no actual emergency, CMS says. The plan can’t require prior authorization for emergency services.  

With some MA plans, if you’re admitted to the hospital within 24 hours, you may not need to pay the copayment for the emergency room visit. Instead, it becomes part of your hospital stay.

How to find the details. Specifics vary by plan. See the plan summary on the website of each private plan or evidence of coverage. You can get to these documents through Medicare’s Plan Finder even if you’re not shopping for new coverage.

Log in if you have an account to see a summary of your current coverage. Or navigate through the Plan Finder by entering your zip code, choosing your coverage year, hitting the Continue button, clicking Medicare Advantage Plan (Part C), tapping the Find Plans button and going though the questions. You don’t need to compare your drug costs, but you do want to get to the list of plans for your area and find your specific plan.

Click the Plan Details button, and on the next page the Plan website link. From there, your provider’s website will walk you through steps to learn information about your plan on its website. You’ll generally see a link to View plan summary or View plan documents within the plan information. Both documents are very detailed but often let you search within for “emergency” so you can find what’s relevant to your situation.

Urgent care also possible. Your Medicare Advantage plan may cover urgent care visits from out-of-network providers. These are nonemergency situations that require immediate medical attention when a network provider is not available, such as when you have a severe sore throat on a weekend and your doctor is off or if you’re traveling outside the plan’s service area.

You’ll have the same copayment as in-network urgent care, which could be around $50. 

How does Medicare cover emergency ambulance services?

Medicare Part B covers emergency ambulance services, but they’re subject to a deductible and 20 percent coinsurance. A supplemental policy should help cover those.

Part B will pay for ambulance transportation to a hospital or skilled nursing facility if traveling in any other vehicle could endanger your health. This applies to emergency transport in an airplane or helicopter if you need immediate and rapid transport that a ground service can’t provide.

Medicare Advantage, too, covers emergency ambulance services, but like its emergency room coverage, its copay rates can be high. You may have a $300 copay for each one-way trip. See the plan’s evidence of coverage for details. 

Keep in mind

Medicare covers emergency room visits throughout the United States, but it typically doesn’t cover emergency care outside the U.S., except in limited circumstances.  

Some Medigap policies cover foreign travel emergency care with a lifetime limit of $50,000. Some Medicare Advantage plans provide limited coverage for foreign travel emergencies. Specifics vary a lot by plan.

Another option is buying travel insurance, which may provide more coverage for emergency care and medical evacuation when traveling. 

Return to Medicare Q&A main page