Let’s learn more about Medicare’s role in covering urgent care treatment.
What Is Urgent Care?
Urgent care is the treatment of a condition, illness, or injury that isn’t severe enough to require emergency room care but does require immediate medical attention. It’s for problems that aren’t life threatening, but require medical attention within 24 to 48 hours. Typically, urgent care centers offer walk-in care that doesn’t require an appointment. Urgent care can address conditions such as:
Colds or fluCuts that only require stitchesDiagnostic services, like laboratory tests or X-raysEye irritationMild to moderate back problemsSore throatSprains
What Does Medicare Cover for Urgent Care?
Medicare Part B does cover urgent care services—or immediate medical care of a sudden illness or injury—to prevent disability or death in cases that aren’t a medical emergency. Original Medicare covers 80% of the Medicare-approved amount of urgent care costs and you pay 20%. The Medicare-approved amount is an amount a medical professional or medical business agrees to accept from Medicare for services. Most doctors and other medical providers “accept assignment,” which means they have agreed to accept the Medicare-approved amount as payment in full. Medical services that accept assignment can only charge you coinsurance and deductible, and they submit your claim to Medicare. Your share is typically due after Medicare pays its share. You can use Medicare’s provider search tool to verify whether a specific urgent care center accepts assignment or to find one near you that charges the Medicare-approved amount. You can also contact Medicare with questions online via live chat or by calling 1-800-MEDICARE. Urgent care services are also subject to Medicare co-payments, typically a set amount like $20. If the provider doesn’t accept assignment, you’ll have to pay any amount that exceeds the Medicare-approved amount, which the law caps at 15% above what Medicare pays for certain services.
Additional Medicare Coverage for Urgent Care
Adding Medigap or to Original Medicare or switching to Medicare Advantage might help enhance your benefits, including Part B’s urgent care coverage.
Medigap
Private insurance companies sell Medigap, a Medicare supplement that helps pay out-of-pocket Medicare costs, like copayments, coinsurance, and deductibles. You can only buy Medigap coverage if you already have Medicare Part A and Part B. Medigap may also cover medical services received outside the United States, which isn’t covered by Original Medicare. If you carry Medigap and get sick or sustain an injury overseas, Medicare will pay the Medicare-approved amount of your medical costs and Medigap will kick in to pay its portion. When you sign up for Medigap, you’ll pay a monthly premium to the private insurance provider and the monthly Part B premium to Medicare. Medigap only covers individuals, so spouses must carry their own policies. Medigap policies feature guaranteed renewal, so the insurer can’t cancel your coverage due to health problems. Medigap policies sold after Jan. 1, 2006, don’t include prescription drug coverage. However, private insurers also sell Medicare’s prescription drug plan, Part D. While you can purchase Medigap and Part D coverages, carriers aren’t allowed to sell Medigap if you already carry a Medicare Advantage Plan (unless you’re switching back to Original Medicare. You can compare plan benefits and see price estimates with the Medigap lookup tool from The U.S. Centers for Medicare and Medicaid Services. Once you find a plan you like, the tool provides a list of Medigap carriers in your area.
Medicare Advantage
Medicare Advantage plans, also called “Part C” or “MA” plans, include Medicare Part A and Part B and are available through private companies. These types of plans cap annual out-of-pocket costs for covered medical services and most include Medicare Part D drug coverage. Typically, Medicare Advantage Plans require you to seek medical services within a network. Common types of plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs), private fee-for-service (PFFSs), and special needs plans (SNPs). Some Medicare Advantage Plans allow you to seek non-emergency medical care, like from an urgent care center, out of network, but usually for a higher cost. You can compare Medicare Advantage Plans using the plan lookup tool on the Medicare.gov website.
Urgent Care vs. Emergency Room Medicare Coverage
If you seek urgent care services, Medicare Part B covers 80% of the Medicare-approved costs and you’ll pay 20%, plus a copayment. The annual Part B deductible also applies to urgent care treatment. Medicare Part B typically covers emergency room services. Medicare covers 80% of the Medicare-approved amount and you pay 20%. You must meet your annual Part B deductible and pay a copayment with each emergency room visit. Medicare Part B also covers ground ambulance costs if you’re transported to a hospital or trauma center. In some cases, Medicare Part B also covers air ambulance transportation.
Know When Urgent Care Makes Sense
Generally, urgent care can handle medical issues that don’t risk disability and aren’t life-threatening. Conditions that might warrant a trip to an urgent care center might include common illnesses such as colds, earaches, the flu, low-grade fevers, migraines, and sore throats. Urgent care professionals can deal with minor injuries, like back pain, minor broken bones, minor cuts, minor eye injuries, and sprains. For major illnesses or serious injuries, call 911. That could include:
Alcohol or drug overdosesBreathing problemsCoughing up or vomiting bloodHead injuries that cause confusion, fainting, or passing outSevere neck or spine injuriesPoisoningSevere allergic reactions that cause breathing difficulty, hives, or swellingHeavy bleeding or bleeding you can’t controlModerate or severe burnsSmoke inhalationSudden confusion or an inability to move, see, speak, or walkSudden severe headaches
