Medicare and Urgent Care: What Is Covered?

Medicare Part B

Medicare does cover urgent care visits. The cost to you will depend on the Medicare plan that you have. If you have parts A and B, known as original Medicare, Part B will cover your urgent care visit.

With Part B, you’ll need to meet the yearly deductible before your coverage starts. In 2020, this deductible is $198. Once the deductible is met, you’ll pay 20 percent of the Medicare-approved cost for all services and tests. Medicare-approved costs are often lower than the standard fee, which means an extra savings benefit.

Medicare Part C

The cost to you might differ if you have a Medicare Advantage (Part C) plan. Medicare Advantage plans are offered by private companies that contract with Medicare. This type of plan offers all the coverage of original Medicare but usually with added benefits, such as dental or vision coverage.

Each Medicare Advantage plan sets its own cost and coverage amounts. The deductible, coinsurance, and premiums you’ll pay depend on the plan you select.

Generally, these plans have a set amount you’ll pay for an urgent care visit. You can shop for plans in your area on the Medicare website.

Will Medicare pay for urgent care if I’m traveling?

It’s possible that you might need to visit an urgent care center while you’re on vacation. A bad sunburn or a sprained ankle on a hike could have you searching for care. If you’re traveling outside the United States, you might not be sure how that care will be paid for.

If you have Medicare, a Medigap plan can help pay your costs when you’re traveling abroad. Medigap is supplemental Medicare insurance that’s sold by private companies to help cover original Medicare costs.

With most Medigap plans, emergency services will be covered for the first 60 days that you’re out of the country. After you’ve paid a $250 deductible, Medigap will cover 80 percent of the cost for medically necessary emergency treatments.

As a Medicare beneficiary, you’ll usually be covered if you visit an urgent care center. Other than a coinsurance or deductible, the most common cost will be for any medications prescribed to you. Original Medicare doesn’t offer prescription drug coverage. You can get medication coverage with a separate Part D plan or as part of your Medicare Advantage plan.

You may pay higher costs up front if you choose an urgent care center or provider that doesn’t participate in Medicare. Most urgent care centers do accept Medicare. Even if you go to one that doesn’t, you have the right to receive care. In this case, the urgent care center will just need to send some additional paperwork to Medicare.

Still, it’s easier to choose an urgent care center that accepts Medicare. If it doesn’t, you could be asked to pay the full amount out of pocket at the time of service. You’ll be reimbursed when Medicare processes the claim.

Will Medicare reimburse me for an urgent care visit?

If you visit an urgent care center or see a physician there that doesn’t participate in Medicare, you can be reimbursed for the out-of-pocket cost. You will likely need to pay the full amount up front, then file a reimbursement claim with Medicare.

You’ll need to submit the following items:

• a receipt showing the amount you paid
• a letter explaining that the urgent care center didn’t accept Medicare coverage
• this completed claim form

Urgent care centers can save you from a trip to the ER, but they can’t treat all conditions. Generally, urgent care is for situations that are not emergencies but can’t wait until you get an appointment with your primary care doctor. The ER is for potentially life threatening situations and serious injuries.

When should I go to urgent care?

You should go to urgent care when you need medical attention quickly but the situation isn’t life threatening. Some of the conditions that can be treated at an urgent care center include:

• insect or animal bites
• sprains
• cold or flu
• allergies
• minor cuts, burns, or fractures
• urinary tract or other bacterial infections

Most urgent care centers keep common medications in stock. You may be able to get them during your visit rather than going to the pharmacy. Urgent care centers can also provide services like physicals, vaccines, drug tests, and bloodwork.

When should I go to the ER?

You should go to the ER if your condition is serious and requires care at a hospital. Examples of conditions that should be treated at the ER include:

• stroke
• heart attack
• seizure
• head injuries
• serious burns
• broken bones
• bleeding that can’t be controlled
• suicidal thoughts
• serious wounds

Any condition that threatens your life or could cause you to lose a limb needs to be treated at the ER.

For example, if you fell and hit your head, you should pay attention to your symptoms to decide where to go. If you’re slightly dizzy and have a dull headache, you should go to an urgent care center to get checked for a possible mild concussion. But if you’re disoriented, confused, slurring your words, or having trouble with your vision, you should go to the ER.

Urgent care costs

Visiting an urgent care center can save you money. The costs at an urgent care center are generally much lower than hospital costs, even for people without insurance. When you visit an urgent care provider, your costs will vary depending on your type of coverage:

• Original Medicare. Once you’ve met your deductible, you’ll pay 20 percent of the Medicare-approved cost.
• Medicare Advantage. You’ll typically pay a flat copay amount (see your plan’s summary of benefits or give them a call). Your costs might be higher if you go to an out-of-network urgent care center.

ER costs

Your costs can add up a lot faster if you visit the ER. If you have original Medicare, you’ll still pay a 20 percent coinsurance fee after your deductible. But ER visits can cost thousands of dollars, depending on the treatment you need. You’ll be charged for each service you receive from the ER. This means that you’ll be paying 20 percent of a much larger number.

Your Part A coverage will kick in if you’re admitted to the hospital. You’ll be responsible for a deductible of $1,408 before your hospital costs are covered. You won’t need to pay the 20 percent copayment if you’re admitted to the hospital within 3 days of going to the ER for the same condition. In this situation, the ER visit will be considered part of your inpatient stay.

Medicare Advantage plans usually have a set copayment for ER visits. The copayment will depend on your plan. Many plans will waive this fee if you’re admitted to the hospital.

How much more will the ER cost?

It’s typically much less expensive to visit an urgent care center than an ER. Let’s take a look at an example below.

Urgent care centers can be a great option for many conditions. They offer many advantages, in addition to cost savings, and are becoming a popular choice. In fact, the Urgent Care Association reports that as of November 2019, there were 9,616 urgent care locations in the United States.

In many parts of the country, you can find urgent care centers in convenient locations, such as strip malls or shopping centers. They tend to have longer hours than traditional doctor’s offices, making it easier to stop in after work or on the weekend.

Other perks of urgent care include:

• shorter wait times
• walk-in service
• the ability to make appointments online
• the ability to sign in online
• wide Medicare acceptance

You can check to see if your nearest urgent care center accepts Medicare by using the find-and-compare tool on the Medicare website.

There are many times when a visit to urgent care is the right choice. Remember that:

• Medicare includes coverage for urgent care.
• Your costs will depend on your plan and whether you’ve met your deductible.
• Urgent care centers are for when you can’t wait to see your primary care doctor; the ER is for conditions that threaten your life or limbs.
• Urgent care centers typically have more locations and more convenient hours than doctor’s offices, as well as lower costs and shorter wait times than the ER.