Medicare Part A serves as hospital insurance within Original Medicare. Coverage for an emergency room (ER) visit is not straightforward, as it depends entirely on the status assigned to the patient after the initial evaluation. The determination of whether a patient is formally admitted or discharged directly impacts which parts of Medicare cover the resulting medical expenses.
Inpatient Admission and Medicare Part A Coverage
Part A coverage for an emergency visit is activated only when a physician formally admits the patient to the hospital following the ER evaluation. A patient achieves “inpatient status” when a doctor writes an order to admit them, with the expectation that the patient will require medically necessary hospital care extending through two or more midnights. This formal admission determines the application of Part A benefits.
Once admitted as an inpatient, Medicare Part A covers the facility costs associated with the hospital stay. These covered services include the semi-private room, meals, general nursing care, and the use of facility equipment and services. Part A covers the facility charges, which are separate from the fees charged by the individual physicians who treat the patient while they are admitted.
Emergency Room Visits Not Resulting in Admission
When a patient visits the emergency department, receives treatment, and is discharged home, Medicare Part A does not provide coverage for the services received. In this common scenario, the emergency care is considered an outpatient service, and the costs are covered by Medicare Part B, the medical insurance component. Part B covers both the facility fees for the emergency department and the professional fees charged by the attending physicians.
The facility charges covered by Part B include the cost of diagnostic tests, such as X-rays or lab work, and the use of the ER treatment areas. A frequently misunderstood scenario is when a patient is kept under “Observation Status,” even if this stay lasts overnight or longer. Observation status is legally defined as an outpatient service. Therefore, all costs incurred during an observation stay, including the ER visit that led to it, fall under Medicare Part B rules.
Financial Responsibility for Emergency Care
The financial responsibility for an emergency room visit depends on the patient’s classification as an inpatient or an outpatient. If the emergency visit leads to a formal inpatient admission, the patient is responsible for the Medicare Part A deductible. This deductible applies per benefit period. For 2024, the Part A deductible is $1,632 per benefit period. Once this deductible is met, Part A covers the full cost of the hospital stay for the first 60 days in that benefit period.
When the emergency visit is treated as an outpatient service, including all observation stays, the financial burden shifts to Medicare Part B. The beneficiary must first meet the annual Medicare Part B deductible, which is $240 in 2024. After the deductible is satisfied, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for most covered services.
This 20% coinsurance applies to the emergency room facility charges, physician professional fees, and any diagnostic testing performed during the outpatient visit. The patient may also owe a separate copayment for the emergency room visit and for each hospital service received.
The cost of ground ambulance transportation to the hospital is typically covered under Medicare Part B, provided the transportation is medically necessary. Medical necessity means that using any other means of transportation, such as a car or taxi, could endanger the patient’s health. The beneficiary is responsible for the Part B deductible and the 20% coinsurance for the ambulance service. If the transport is determined not to be medically necessary, the beneficiary may be responsible for the full cost.