Medicare covers emergency room visits, but not always at 100 percent — what you pay depends on your coverage type and whether the hospital is in your plan's network.

If you have Original Medicare (Part A and Part B), the program pays its share of the ER bill after you meet your deductible. You are responsible for a copay or coinsurance — a fixed amount or a percentage of the cost. If you have a Medicare Advantage plan, your out-of-pocket costs work differently and are often lower, but you may face higher bills if you go to an out-of-network hospital.

The amount you pay is not the same across all ER visits. It depends on whether the visit results in admission to the hospital, whether the hospital is in your plan's network, and what your specific plan covers. Understanding these rules before an emergency happens helps you know what to expect.

Key Takeaways

  • Original Medicare covers ER visits after you pay your Part B deductible, then you pay 20 percent coinsurance for the emergency department visit itself.
  • If the ER visit leads to hospital admission, your Part A deductible applies instead, and you pay nothing for the first three days of inpatient care.
  • Medicare Advantage plans have their own copays and coinsurance rules, which vary by plan and are often lower than Original Medicare's 20 percent.
  • Out-of-network ER visits may cost you significantly more under Medicare Advantage, even in a true emergency.
  • You should call your plan or check your member handbook before an ER visit if you have time, because your costs depend on your specific coverage.

How Original Medicare Covers Emergency Room Visits

Under Original Medicare, the emergency room is covered as an outpatient service under Part B. After you pay your annual Part B deductible (which changes each year), Medicare pays 80 percent of the approved amount for the ER visit, and you pay the remaining 20 percent as coinsurance. This 20 percent is your responsibility, even if the hospital is in-network, because that is how Original Medicare structures outpatient care.

The "approved amount" is what Medicare decides the service is worth — not necessarily what the hospital charges. If the hospital bills more than Medicare's approved amount, you may owe the difference as well, depending on whether the hospital accepts Medicare assignment. Most hospitals do, which means they agree not to bill you for the overage.

The ER visit itself is separate from any tests, imaging, or procedures done during that visit. An X-ray, blood work, or CT scan will have its own approved amount and its own 20 percent coinsurance. Your total out-of-pocket cost for an ER visit can add up quickly if multiple services are performed.

What Changes If You Are Admitted to the Hospital

If your ER visit results in hospital admission, the rules shift. Your Part A deductible applies instead of Part B coinsurance. For 2024, the Part A deductible covers your first three days of inpatient care at no cost to you. Starting on day four, you pay a daily copay (the amount varies by year) for days four through sixty. After day sixty, your costs increase further.

This is one reason why it matters whether the ER visit leads to admission: if you are admitted, you may actually pay less overall than if you are treated and released. The ER copay disappears, and your Part A deductible covers the first three days. However, if you stay longer than three days, the daily copays add up.

Medicare considers you "admitted" when a doctor formally orders inpatient admission. Being in the hospital overnight does not automatically mean you are admitted — you could be on "observation status," which is treated as outpatient care and means you pay the ER-visit coinsurance instead. Ask the hospital staff directly whether you are being admitted or held for observation, because the difference affects your bill.

Medicare Advantage Plans and Emergency Room Costs

Medicare Advantage plans (Part C) are required to cover emergency room visits, but each plan sets its own copay or coinsurance. Many plans charge a flat copay for an ER visit — often $100 to $250 — rather than the 20 percent coinsurance you would pay under Original Medicare. For a small ER bill, this flat copay may cost you less. For a large bill with imaging and procedures, it may cost you more.

The critical rule for Medicare Advantage is that you must use in-network providers to get the plan's negotiated rates. If you go to an out-of-network ER, you may pay much more — sometimes the full bill, depending on your plan. Even in a true emergency, some plans do not waive the out-of-network penalty. Read your plan's member handbook or call the plan before an ER visit if you have time to confirm whether the hospital is in-network.

Some Medicare Advantage plans waive the copay if the ER visit results in admission. Others do not. This varies widely, so check your specific plan documents. If you are unsure, call your plan's member services line and ask: "If I go to the ER and am admitted, do I owe a copay for the ER visit?"

Out-of-Network Emergency Room Visits

Original Medicare covers emergency room visits at any hospital, whether in-network or not, because Original Medicare does not have networks. You pay the same 20 percent coinsurance regardless of where you go. This is one advantage of Original Medicare in a true emergency — you do not have to worry about finding an in-network hospital.

Medicare Advantage plans, however, do have networks. If you go to an out-of-network ER, you may owe a higher copay, higher coinsurance, or even the full bill depending on your plan. Some plans do cover out-of-network emergency care at the in-network rate if it is a true emergency, but you have to check your plan documents to know. The definition of "emergency" also varies by plan — some are strict, others are broad.

If you have a choice of hospitals during an emergency, call your Medicare Advantage plan's member services line (the number is on your card) and ask which hospitals are in-network. If you do not have time to call, go to the nearest hospital and ask the billing department to contact your plan to confirm coverage before you are treated.

What You Should Do Before an Emergency Happens

Write down your Medicare plan type and member ID number and keep it somewhere you can find it quickly. If you have Original Medicare, write down that you have Part A and Part B. If you have a Medicare Advantage plan, write down the plan name and the member services phone number (on the back of your card).

If you have Original Medicare, know that you will owe 20 percent coinsurance for the ER visit after your Part B deductible. If you have a Medicare Advantage plan, call your plan now and ask: What is my copay for an ER visit? Which hospitals are in-network? What happens if I go out-of-network in an emergency? Write down the answers.

If you are worried about ER costs, ask your doctor about urgent care clinics in your area. Urgent care is often cheaper than the ER and is covered by Medicare if the clinic is a Medicare-participating provider. Urgent care is appropriate for sprains, minor cuts, infections, and other non-life-threatening problems. The ER is for chest pain, difficulty breathing, severe injuries, and other emergencies.

Costs Beyond the ER Visit Itself

The ER visit copay or coinsurance is only part of your bill. Any tests, imaging, or procedures done in the ER are billed separately. Under Original Medicare, you pay 20 percent coinsurance for each of these services after your Part B deductible. Under Medicare Advantage, your plan's copay or coinsurance structure applies to each service as well.

If the ER doctor orders an ambulance to transport you, that is covered by Medicare Part B, and you pay 20 percent coinsurance under Original Medicare. If you are admitted and the hospital keeps you for observation or inpatient care, additional charges explore based on your admission status and length of stay.

Ask the hospital billing department for an estimate before you leave the ER if you can. They may not have a final number, but they can tell you what services were billed and give you a rough idea of what your share might be. Request an itemized bill so you can see exactly what you are being charged for.

Frequently Asked Questions

Do I have to pay anything if I go to the ER with Original Medicare?

Yes. After you meet your Part B deductible, you pay 20 percent coinsurance for the ER visit. Any tests or procedures done during the visit have their own 20 percent coinsurance as well. If the visit results in hospital admission, your Part A deductible applies instead, and you pay nothing for the first three days.

What is the difference between being admitted and being on observation?

Admitted means a doctor has formally ordered inpatient hospital care, and your Part A deductible applies. Observation means you are being monitored but not formally admitted, and you are treated as an outpatient — you pay the ER visit coinsurance instead. Ask the hospital staff directly which status applies to you, because it affects your bill significantly.

Will Medicare Advantage cover an out-of-network ER visit?

Most plans cover out-of-network emergency care, but you may pay more than you would at an in-network hospital. Some plans charge a higher copay or coinsurance for out-of-network care. Check your plan documents or call member services to find out your plan's specific rule.

Can I find out what I will owe before I go to the ER?

Not exactly — ER costs depend on what services you need, which is not known until you are evaluated. However, you can call your plan now and ask what your copay or coinsurance is for an ER visit. That gives you a baseline. For a more detailed estimate, ask the hospital billing department after the visit.

What if I cannot afford to pay my ER bill?

Ask the hospital's financial information or patient advocate office about payment plans or financial hardship programs. Many hospitals offer reduced bills for people with low income. Do not ignore the bill — contact the hospital to discuss your options before the account goes to collections.