You never know when an emergency will arise, but you can be prepared. Let’s discuss Medicare’s coverage of emergency and urgently needed care.
First, how do we define emergency and urgently needed care?
Emergency care is needed to evaluate or treat emergency medical conditions. An emergency medical condition is severe enough that someone with an average knowledge of health and medicine could reasonably expect your health to be in danger if you don’t get medical attention right away. If you’re pregnant, this could also mean that the health of the fetus is in danger. Urgently needed care is immediately required care because of an unexpected illness, injury, or condition. These definitions are especially important if you have a Medicare Advantage plan. There are certain protections you have if you need emergency or urgent care outside your plan’s network.
How does Medicare cover emergency room services?
If you have Original Medicare, Part B covers emergency room services anywhere in the U.S. Emergency room services are typically provided when you have a medical condition that requires immediate action, such as an injury or sudden illness.
Contact Medicare if you have specific questions about Original Medicare coverage of emergency or urgently needed care. You can call 1-800-MEDICARE or visit www.Medicare.gov.
If you have a Medicare Advantage plan, your plan must cover emergency room services anywhere in the country. Your plan cannot require you to see an in-network provider or get a referral. There are limits on how much your plan can bill you if you receive emergency care while out of your plan’s network. Your plan must also cover medically necessary follow-up care related to the emergency if delaying care would endanger your health. Remember that you have the right to appeal if your plan denies coverage.
Contact your Medicare Advantage plan to learn about your plan’s coverage and costs related to emergency and urgently needed care.
If your condition was not an emergency but appeared to be an emergency at the time, Original Medicare or your Medicare Advantage plan must still cover your care. For example, let’s say you have chest pain and think you are having a heart attack. If you go to the emergency room and doctors discover that your pain is heartburn, your care should still be covered because the situation seemed to be an emergency.
How does Medicare cover ambulance transportation?
If you have Original Medicare, Part B covers emergency ambulance services if:
- An ambulance is medically necessary, meaning it’s the only safe way to transport you
- The reason for your trip is to get a Medicare-covered service or return from getting care
- You are transported to and from certain locations, following Medicare’s coverage rules
- And, the transportation supplier meets Medicare ambulance requirements
To be eligible for coverage of non-emergency ambulance services, you must be bedbound or need essential medical services during your trip that are only available in an ambulance. This could include administration of medications or monitoring of vital functions. Original Medicare never covers ambulette services.
If you have a Medicare Advantage plan, your plan must cover the same services that Original Medicare covers but can do so with different costs or restrictions. Contact your plan directly to learn more about how it covers ambulance transportation.
Finally, look out for and report ambulance fraud, errors, or abuse.
Here are some red flags to watch for:
- You were transported in an unapproved ambulance like a taxi, van, or rideshare.
- An ambulance company billed for more mileage than the actual distance of your ambulance trip.
- An ambulance was arranged for you, even though it wasn’t an emergency or medically necessary for you.
- You were transported from your house to a non-covered destination, like your doctor’s office or a community health center.
If you believe you have experienced ambulance fraud, errors, or abuse, you should contact your local Senior Medicare Patrol, or SMP. You can use the online SMP Locator or call 877-808-2468.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
If you think you have experienced potential Medicare fraud, errors, or abuse contact your local Senior Medicare Patrol using the online SMP Locator or by calling 877-808-2468.