Medicare Part A covers inpatient services, meaning you must admitted as an inpatient for Part A to apply.
Although Medicare Part A is often referred to as “hospital insurance”, it has a more complicated relationship with emergency room care. Although emergency rooms are part of hospitals physically, emergency room care is not considered to be inpatient care under most circumstances. Part A technically covers inpatient hospital services, not all hospital services generally. Inpatient care includes hospitals, skilled nursing facilities, and hospice care.
So, what Part A covers is a little bit more complicated. We’ll get into the details here, so you can know what to expect before your emergency room visit.
What Does Part A of Medicare Cover?
Part A of Medicare covers inpatient care in a hospital. If you have a hospital stay that doesn't involve receiving inpatient care,it will not be covered by Medicare Part A. Part A also covers skilled nursing facility care, hospice care, some in-home health care, and nursing home care. Although most hospital stays will be covered by Part A, it will depend on the circumstances.
What Is the Difference Between Inpatient and Outpatient Care?
Understanding the difference between inpatient and outpatient care is important because this often determines which part of Medicare will cover your medical fees. Inpatient care involves receiving medical care overnight and specifically requires the length of your stay to be directly related to your medical care. If you stay in the emergency room just a bit later than midnight in order for some anesthesia to wear off, for example, then your stay will likely not be counted as inpatient care, and may not be covered by Part A.
Outpatient care refers to medical services that don’t require you to stay the night. This is usually associated with care received at doctor’s offices, but emergency room care is often outpatient care as well, since you may be released the same day. There are some occasions where you may have to stay overnight and the care you receive still won’t count as outpatient care if it is due to incidental reasons that don’t directly relate to the length of time it takes you to receive your medical care.
Lengthy Outpatient Stays and MOON Forms
If you are staying at an emergency room or hospital setting for over 24 hours but are not receiving inpatient care, then the hospital will be required to give you a Medicare Outpatient Observation Notice, or MOON form. This will explain the conditions of your stay, and let you know in writing that you will be receiving outpatient care that requires a lengthier stay, not inpatient care. If you receive a MOON form, you should expect to be covered under Part B, not Part A.
It’s important to note that there is no way to appeal the outpatient designation that comes with a MOON form. You may be able to appeal other features of your medical care after the fact, but this isn’t true with MOON forms.
The Two-Midnight Rule
A general rule that determines inpatient designation is known colloquially as the “two-midnight rule”. If your doctor expects you to stay in the hospital for a time period that crosses two midnights, then you will be admitted as an inpatient.
For example, if you enter the emergency room on Monday at 11:30 PM, and are expected to be discharged on Wednesday morning, then your stay will cross two midnights: 12:00 AM on Tuesday, and 12:00 AM on Wednesday. In this case, you will most likely be admitted as an inpatient. But do not assume! It's still important to ask a member of the hospital staff what your status is.
When Will Part A Cover Emergency Room Visits?
Although Part A doesn’t always cover emergency room visits, there are situations where it will. Specifically, if you are admitted to the same hospital within three days of your initial emergency room visit. In this case, your emergency room visit is considered to be part of your inpatient stay, so it will be covered by Part A, just like the rest of your hospital visit.
If you are admitted to the hospital under this circumstance, you won’t be responsible for any copayment.
Part B Coverage: Emergency Room Visits With No Hospital Admission
If you go to the emergency room and are treated as an outpatient, then you will receive Medicare coverage under Part B, not Part A. In this scenario, your coverage will function the same way as if you were at your normal doctor’s office.
Medicare Part B: Additional Fees
You will be responsible for a copayment for each visit, as well as 20 percent of the Medicare-approved amount. Your Part B deductible will also apply for outpatient visits to emergency rooms. If you receive a MOON form, that is one way to know that you will be responsible for these fees.
Does Medicare Advantage Cover Emergency Room Visits?
All Medicare Advantage plans are required by law to provide the same coverage as Original Medicare, which means that all of the same rules we described above will hold for Medicare Advantage. Your Medicare Advantage plan may have distinct copayment and deductible amounts compared to Original Medicare, so make sure you know what these amounts are for your specific plan.
One other thing to keep in mind is that your Medicare Advantage plan will function as either an HMO or PPO plan. Although HMO plans have restricted provider networks, this doesn’t apply when it comes to emergency care. So, even if the hospital that you go to is not part of your provider network, your plan will still cover it in the usual way. This also goes for other forms of emergency care, like emergency dialysis care. With PPO plans, there won’t be any issue with your coverage.
Does Part D Cover Prescription Drugs in the Emergency Room?
Receiving some prescription drugs during your emergency room visit is common. Although Part D plans are usually what covers prescription drugs, you will be covered by your Part A or Part B plan for most drugs administered as part of your emergency room visit.
In general, if you don’t administer the drug yourself, it will be considered as part of your inpatient or outpatient care, not as a distinct prescription drug. Many self-administered drugs will also be covered by your Part A or Part B plan if they are part of the medical care you receive during your visit. However, drugs that are prescribed to be taken after you are discharged from the hospital will not be covered by Original Medicare. To cover these drugs, you’ll need a Part D plan or another health insurance plan that covers drug prescriptions.
Can Medigap Help With Emergency Room Coverage?
Medigap plans, or Medicare Supplement plans, can help with your emergency room coverage under specific circumstances. While Medigap plans don’t cover medical care directly, they do help you pay for your deductibles, copayments, and coinsurance payments. If you are admitted to the emergency room as an outpatient and covered under a Part B plan, then your Medigap plan may be able to help you cover your deductible, copayment, coinsurance, or various other fees.
There are many Medigap plans out there, so you should make sure that the one that you have covers the relevant fees.
What About Urgent Care?
Urgent care centers are common for sudden illnesses and conditions that are serious, but not life-threatening. As far as Medicare is concerned, urgent care centers involve outpatient care, so they will be covered by Part B. This means that all of the same conditions will apply as they would for outpatient care in an emergency room: you will have a copayment, pay 20 percent of the Medicare-approved amount, and your deductible will apply.
What to Expect From An Emergency Room Visit
Emergency room visits can be stressful, so understanding what to expect can help keep you calm and prepared. In general, expect for your care to fall under Part B, and for the relevant fees like your deductible and copayment to apply. If you stay in the hospital for a longer period but receive a MOON form, then you should expect to be covered under Part B as well.
If you have Medicare Advantage, make sure that you understand what your copayment, coinsurance and deductible amounts are, since this will probably be relevant for your stay as an outpatient. Having all of this information in mind can help keep you prepared and make all of your emergency room visits surprise-free.