Medicare offers coverage for emergency room visits, but your cost-sharing responsibility will depend on several factors: your admission status, recommended treatment, and what kind of Medicare plan you’re enrolled in. Today, we’re going to review a few different situations so you can be better prepared for emergency room copays.
Original Medicare and Emergency Room Visits
Original Medicare consists of two parts: Part A and Part B. Part A serves as your hospital or inpatient insurance, while Part B is your medical or outpatient insurance. The coverage you have during an emergency room visit will depend on how you’re admitted.
If you walk into the emergency department, or if you’re transported by ambulance, you’re considered an outpatient, at least at first. You may even stay overnight at the hospital and still be considered an outpatient in some cases. If you have an outpatient status, your coverage falls under Medicare Part B.
Part B has two costs associated with it: a deductible and coinsurance. Currently (2022), the Part B deductible is $233 per year. This will be your first expense during an emergency room visit unless you’ve already paid it for the year. Once you meet that deductible, you’ll pay about 20% in coinsurance amounts. You may be charged for the visit, for x-rays, or for lab tests. All these fall under Medicare Part B. Generally, the sum of these charges won’t exceed the Part A deductible, which is $1,556 this year.
You only become an inpatient when a doctor writes an order and formally admits you to the hospital. In most cases, this occurs when the doctor believes you’ll need at least two nights of hospital care. If you’re admitted as an inpatient, that’s when Medicare Part A kicks in.
Part A also has two different costs. As we mentioned, the current deductible is $1,556. Unlike Part B, this is not an annual deductible but, rather, applies to every benefit period. A benefit period begins on the first day of your inpatient admission and ends when you’ve been hospital-free for 60 consecutive days. After you’ve met your deductible, your coinsurance amount will depend on how many days you’ve been in the hospital. The first 60 days are completely covered by Medicare.
If your admission status gets changed from outpatient to inpatient, you will not be responsible for the charges related to the emergency room visit. In addition, your admission must be at the same hospital where you received emergency room care. If you’re admitted to a different hospital within three days of your ER visit, it will be considered a separate event, and all charges will apply.
Medigap and Emergency Room Visits
Most Medicare beneficiaries choose to supplement their coverage under Original Medicare. One of the ways they might choose to do so is with a Medigap plan, also known as a Medicare Supplement plan.
If you have a Medigap plan, Original Medicare is still your primary insurance. Once Parts A and B have paid, the claim gets sent to your Medigap plan. Medigap plans will pick up some or all of the remaining costs (all the deductibles and cost-sharing), depending on which Medigap plan you have. For example, Plan G will pay for all remaining costs except the Part B deductible. Plan N, on the other hand, will leave you with the Part B deductible as well as a copayment of up to $50 if you don’t become an inpatient during your ER visit.
Medicare Advantage and Emergency Room Visits
Medicare Advantage plans, also known as Medicare Part C, work a bit differently. Instead of acting as your secondary insurance plan as Medigap plans do, they are an alternative to Original Medicare. Your medical claims will go directly to the private insurance company that provides your Part C plan.
Medicare Advantage plans are all different, but they all include emergency room coverage. MA plans work best when you can use a contracted doctor or hospital, but they all provide coverage in emergency situations, regardless of which hospital you go to (within the United States). Your copayment, however, will depend on your specific plan.
For example, a plan may have a flat copayment amount for an emergency room visit. Or, it may have an emergency room copay and a coinsurance amount for services. You’ll need to review your plan’s evidence of coverage to find out what you’ll be responsible for if you visit an emergency room.
Have questions about your Medicare plans? The agents at Bobby Brock Insurance can help! Our advisors are experts in the Medicare field and can answer questions about your plans or help you enroll for the first time. Call today for a complimentary consultation.