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Medicare and Emergency Room Visits

The priority in any medical emergency is to provide immediate medical care. In almost all cases,  it involves medical teams rushing patients to an emergency room at the nearest hospital.

Emergency room visits cost anywhere between $150 to $3000, or even more for severe cases. This situation can be very stressful, especially for seniors who are unemployed and living on a  pension. Medicare helps to address this need for financial support by providing coverage for many medical services and treatments.

emergency room doctors

Are You Qualified for Medicare Coverage for Emergency Room Visits?

People who are 65 years of age and older, and those currently receiving Social Security benefits for 24 months are eligible for Medicare Part A coverage. However, those planning to include Medicare Part B (medical insurance) coverage are required to enroll and pay a premium along with a yearly deductible.

People who would like to enroll in Medicare Part B are encouraged to apply during the Initial Enrollment Period (IEP) to avoid late enrollment penalties. The IEP is around seven months or 3 months before and 3 months after your 65th birthday.

Medicare is a federal health insurance program designed to help seniors and people with disability pay for medical treatment and services. Medicare provides coverage for emergency room visits. But these are mostly covered under Medicare Part B. Medicare Part A only includes emergency room visits that result in an inpatient hospital stay.

Emergency room services are considered as outpatient hospital services. It is important to know the difference between inpatient or outpatient services because this affects the amount of Medicare covers and the payments you make. Standard emergency room services covered by Medicare include:

  • Laboratory and diagnostic tests
  • X-rays and other radiology tests
  • Emergency surgical procedures
  • Certain drugs and medications
  • Observation, preventive, and screening services

How Much Will Medicare Pay? 

Emergency room visits that result to an inpatient stay is covered under Medicare Part A. Beneficiaries must first pay the Part A deductible before Medicare benefits kick in. Coinsurance for 2019 are as follows:

  • $0 for each benefit period for a hospital stay of 1 to 60 days
  • $341 for each benefit period for a hospital stay of 61 to 90 days
  • $648 for each benefit period per each “lifetime reserve day” beyond 90 days
  • All costs beyond “lifetime reserve day”

Medicare beneficiaries are expected to make copayments for the emergency room visits and each hospital service rendered. These payments are also subject to the services received and where it was performed.

Aside from emergency room copays, Medicare beneficiaries should also consider deductibles and coinsurance.

Medicare Part B covers emergency room visits in a hospital emergency department. Patients are expected to pay the annual Part B deductible of $185 (2019) before Medicare makes any payments.

Beneficiaries are also expected to make a coinsurance payment of 20 percent of the Medicare-approved amount for doctor’s services and treatments.

Patients who are admitted to the same hospital within three days of the original visit for a related condition are exempted from copayments because this is considered to be an inpatient stay.

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