What It Is
Hospital or clinic emergency room treatment
Medicare Part B covers medically necessary treatment in a hospital or clinic emergency room.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for emergency room treatment, contact the plan directly.
What Medicare Pays
Charges for an emergency room visit are usually broken out into two or more parts. There's a charge by the emergency room itself, for which Medicare Part B pays the full Medicare-approved amount, except for a patient co-payment. (This co-payment is waived if the patient is admitted to the hospital, for the same condition, within three days of the emergency room visit.)
There may also be separate charges for each specific medical service (such as X-rays or an EKG) received in the emergency room. For these services, Medicare Part B pays 80 percent of the Medicare-approved amount.
Also, a doctor who cares for a patient in the emergency room usually bills the patient separately. Medicare Part B pays 80 percent of the Medicare-approved amount for the doctor services.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.