What Medicare Pays for Emergency Room Visits

Medicare covers emergency room visits, but what you pay depends on which part of Medicare you have and whether the ER visit is deemed medically necessary

If you have Original Medicare (Part A and Part B), the emergency room visit itself is covered. Medicare Part B pays 80 percent of the cost after you meet your annual deductible, and you pay the remaining 20 percent coinsurance. If you are admitted to the hospital through the ER, Part A covers your inpatient stay under hospital insurance rules instead.

If you have a Medicare Advantage plan (Part C), your coverage works differently. Most Advantage plans cover ER visits, but you typically pay a copay — often $150 to $300 per visit — regardless of whether you are admitted. Some plans waive the copay if you are admitted to the hospital within a certain number of hours.

The catch is that Medicare only covers ER visits that are medically necessary. If the ER determines your condition was not an emergency, Medicare may deny the claim, and you could owe the full bill. This happens most often when someone goes to the ER for a non-urgent problem that could have been handled in an urgent care clinic or doctor's office.

Key Takeaways

Original Medicare covers 80 percent of ER costs after your Part B deductible; you pay 20 percent coinsurance.
Medicare Advantage plans usually charge a copay of $150 to $300 per ER visit, with some plans waiving it if you are admitted.
Medicare only pays if the visit is medically necessary; non-emergency ER visits may result in you owing the full bill.
If you are unsure whether your symptoms warrant an ER visit, calling your doctor or a nurse hotline first can help you avoid an unnecessary trip and bill.

How Original Medicare Covers Emergency Room Costs

With Original Medicare, your ER visit is covered under Part B (medical insurance) unless you are admitted to the hospital. You pay your Part B deductible once per year — $240 in 2024, though this amount changes yearly — and then Medicare pays 80 percent of the approved amount for the ER visit. You are responsible for the remaining 20 percent coinsurance.

The bill you receive depends on what happens during the visit. If the ER doctor treats you and sends you home, you pay coinsurance on that ER visit only. If the doctor admits you to the hospital, your coverage switches to Part A (hospital insurance), and your costs follow inpatient rules instead: you pay an inpatient deductible (which is separate from your Part B deductible) and then a daily copay for days 4 through 60 of your stay.

Original Medicare does not cover the full cost, so many people with Original Medicare also carry Medigap (supplemental insurance) to cover the 20 percent coinsurance and deductibles. If you have Medigap, your supplemental plan may pay some or all of your ER coinsurance, depending on which Medigap plan you own.

How Medicare Advantage Plans Cover Emergency Room Visits

Medicare Advantage plans are required by law to cover emergency room visits, but the way you pay is simpler and more predictable than Original Medicare. Most Advantage plans charge a fixed copay for an ER visit — typically $150, $200, or $300 — and that is all you owe at the time of service, regardless of what tests or treatments you receive.

Many Advantage plans waive the ER copay if you are admitted to the hospital within 24 or 72 hours of the ER visit. This means if you go to the ER and are then admitted as an inpatient, you may not owe the copay. Check your plan documents or call your plan's customer service number to confirm whether your specific plan has this waiver.

Some Advantage plans charge different copays depending on whether you go to an in-network or out-of-network ER. In-network ERs (usually hospitals in your plan's network) cost less than out-of-network ERs. However, emergency rooms are required to treat you regardless of network status, so go to the nearest ER if you believe you are having an emergency — you can sort out the network question later.

When Medicare May Not Cover Your ER Visit

Medicare covers an ER visit only if it is medically necessary. This means a reasonable person would believe the symptoms or condition required when ready evaluation and treatment to prevent serious harm. A broken bone, chest pain, difficulty breathing, severe bleeding, or sudden loss of consciousness are clearly emergencies. A minor cut, a mild headache, or a rash that has been present for weeks are not.

The problem is that you decide whether to go to the ER based on how you feel, but Medicare decides whether it was necessary based on what the ER actually found. If you go to the ER with what feels like a heart attack and the ER determines it was heartburn, Medicare may still cover the visit because your symptoms were reasonable grounds for seeking emergency care. But if you go to the ER for a sore throat and the ER finds nothing serious, Medicare might deny the claim and send you a bill for the full amount.

If Medicare denies your ER claim, you have the right to appeal. You can ask the hospital to reconsider, or you can file a formal appeal with Medicare. Keep copies of your medical records from the visit and any documentation of your symptoms at the time.

What to Do Before Going to the Emergency Room

If you are unsure whether your symptoms warrant an ER visit, call your primary care doctor first. Many doctor's offices have nurse lines that can help you decide whether you need emergency care or whether urgent care or a same-day appointment would be appropriate. If you cannot reach your doctor, many health insurance plans offer nurse hotlines — check your insurance card or plan documents for the number.

If you have Medicare Advantage, your plan may have a nurse hotline specifically for members. Calling before you go can help you avoid an unnecessary ER visit and the copay that comes with it. However, if you truly believe you are having an emergency — chest pain, difficulty breathing, severe injury, signs of stroke — do not delay. Go to the ER when ready and sort out the coverage questions afterward.

Keep your Medicare card with you at all times. When you arrive at the ER, tell the staff you have Medicare and provide your card. This ensures the hospital bills Medicare correctly and you are not charged as an uninsured patient.

Out-of-Network Emergency Rooms and Travel

If you have Original Medicare, you can go to any ER in the United States that accepts Medicare, and coverage is the same whether the hospital is in-network or out-of-network. This is one advantage of Original Medicare for people who travel or live part of the year in different locations.

If you have a Medicare Advantage plan, coverage outside your plan's service area depends on your specific plan. Some Advantage plans cover out-of-network emergency care at the same copay as in-network care. Others charge a higher copay or require you to pay more coinsurance. If you travel frequently or spend time in multiple states, review your plan documents or call your plan to understand your out-of-network ER coverage before you travel.

Questions to Ask Your Doctor or Insurance Plan

Before an emergency happens, ask your primary care doctor which ER you should go to if you need emergency care. Some doctors are affiliated with specific hospitals, and knowing this in advance can help you make a faster decision if you are in crisis.

Call your Medicare plan — either Medicare directly if you have Original Medicare, or your Advantage plan if you have Part C — and ask: What is my ER copay or coinsurance? Does my plan waive the copay if I am admitted? What happens if I go to an out-of-network ER? Having these answers now means you will not have to figure them out in the middle of a medical emergency.

Frequently Asked Questions

Will Medicare cover an ER visit if I do not have my Medicare card with me?

Yes, Medicare will still cover the visit. The hospital can look up your Medicare information using your Social Security number. However, bring your card whenever possible to speed up the check-in process and reduce the chance of billing errors.

What if the ER bills me for the full amount and says Medicare denied it?

Ask the hospital for a copy of the denial letter from Medicare. Review it to understand why the claim was denied. You have the right to appeal within 120 days. Contact Medicare at 1-800-MEDICARE or file your appeal online through your Medicare account at Medicare.gov.

Does Medicare cover ER visits for mental health crises?

Yes. If you are experiencing suicidal thoughts, severe depression, or another mental health emergency, an ER visit is covered under the same rules as any other medical emergency. You can also call the 988 Suicide and Crisis Lifeline (call or text 988) for when ready support.

If I go to urgent care instead of the ER, will Medicare cover it?

Yes, Medicare Part B covers urgent care visits. You pay your deductible and then 20 percent coinsurance, just as you would for an ER visit. Urgent care is often a lower-cost option for non-emergency problems, so calling your doctor first to determine whether urgent care is appropriate can save you money.

Can I be charged for an ER visit if I am not admitted to the hospital?

Yes. Whether you are admitted or sent home, you owe your share of the ER visit cost. With Original Medicare, you owe 20 percent coinsurance after your deductible. With Advantage, you owe your plan's ER copay. Being sent home does not mean the visit is free.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.