Yes, Medicare does cover urgent care, so long as you have kept up on your Part B monthly premiums and visit a facility that accepts Medicare. Medicare Part B covers 80% of costs assessed at an approved urgent care center, leaving beneficiaries to pay the remaining 20% coinsurance and their annual $226 Part B deductible out of pocket.
Urgent care centers perform minor procedures to treat pressing, albeit nonemergency, issues such as sprained ankles, low fevers, and wounds needing stitches. Though Medicare will pay for emergency and urgent care in most situations, you must ensure you visit a Medicare-approved health provider within United States borders to guarantee coverage.
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What Is Urgent Care?
Urgent care provides professional healthcare services to individuals experiencing unexpected illnesses or injuries not on the level of a medical emergency. Everyday situations that could justify a visit to urgent care include:
- Minor cuts or burns
- Small fractures
- Sprains
- Cold or flu
- Low fever
- Rashes
- Vomiting or diarrhea
- Allergies
- Bacterial/viral infections (UTIs, sinus infections, etc.)
Suppose you had one of these symptoms but could not secure a timely appointment with your primary care provider. Urgent care would offer the same-day professional services necessary to treat, manage, and keep your ailment from progressing. However, if you believe you could be at serious risk of losing your life or use of a limb, immediately seek emergency room attention.
How Does Medicare Coverage of Urgent Care Work?
Medicare coverage for urgent care hinges on your plan type and whether or not you meet its eligibility requirements.
Eligibility
Medicare classifies urgent care under “emergency department services” coverage. According to Medicare bylaws, Medicare Part B must cover all emergency department services within national borders. Therefore, any sudden conditions or injuries that could quickly worsen without immediate medical attention should qualify for Medicare-covered urgent care.
While most Medicare beneficiaries have Part A and Part B, some members with premium-free Part A can choose not to purchase Part B. To guarantee urgent care coverage, you must ensure you have opted into Medicare Part B and kept up on your monthly premiums. Furthermore, though most urgent care centers accept Medicare assignment, non-participating facilities can charge higher rates for Medicare patients or deny coverage altogether.
How Does Original Medicare Cover Urgent Care?
Original Medicare is government-subsidized health insurance composed of two parts: Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Medicare Part B covers all doctors’ services, whether provided by your PCP, emergency room technicians, or urgent care professionals. Since urgent care often proves medically necessary in treating and preventing ailments from worsening, Medicare imposes no limits on how often you can visit participating facilities.
Medicare Part B will also cover 80% of any durable medical equipment, such as crutches or oxygen supplies, required to manage your condition after treatment. However, Part B would not pay for a follow-up medication regimen. Patients must pay for prescription drugs out of pocket or share costs through optional Medicare Part D coverage.
How Does Medigap Cover Urgent Care?
Medicare Supplement, or Medigap, helps cover “gaps” in Original Medicare coverage such as deductibles, coinsurances, and copays. However, the amount that Medigap covers varies by plan. Some plans have a high deductible and therefore would not contribute money towards services until the deductible has been met, such as Plans F and G. Keep in mind that this varies by state.
Further, Medigap coverage rules vary based on your plan type and the private company overseeing it, so verify your policy details before seeking care.
Medigap may also help cover the excess charges incurred by members who receive urgent care at non-Medicare-approved facilities. Unlike Original Medicare, many Medigap plans also help pay for emergency service costs accrued while traveling abroad.
How Does Medicare Advantage Cover Urgent Care?
Even though private insurers provide Medicare Advantage (Part C) coverage, the law requires them to offer equal or greater benefits to Original Medicare. Therefore, at least in theory, all Medicare Advantage plans must cover urgent care services.
However, these plans follow the same private insurance practices that restrict members to a limited network of doctors, pharmacies, and health centers, meaning only some urgent care providers will accept your Medicare Advantage policy. To guarantee coverage under Medicare Advantage, you must ensure that your preferred urgent care facility is in your network. If not, you must pay for its medical services entirely out of pocket.
Choosing Between Urgent Care and ER
Urgent care centers provide medical attention for unexpected, nonemergency injuries or illnesses. Anyone experiencing a more severe condition requiring hospital care should immediately seek emergency room attention. Common symptoms justifying a visit to the ER include:
- Stroke
- Heart attack
- Seizure
- Uncontrollable bleeding
- Trauma to the head or neck
- Severe wounds or burns
- Broken bones
- Respiratory failure
- Severe allergic reactions
- Consumption of or exposure to fatal toxins
When in doubt, if you believe an injury or condition could cost you your life, the use of a limb, or potential organ or brain damage, go to the ER right away. Though Medicare covers ER care, it will cost exorbitantly more than an urgent care visit.
What Services Are Not Available With Urgent Care?
Urgent care facilities employ most of the same medical personnel you’d find at any other health center or hospital. However, unlike the ER, urgent care centers do not have the proper equipment, trauma surgeons, or resources to treat life-threatening illnesses and injuries.
For example, if you needed an immediate blood transfusion or emergency surgery for a gunshot wound, an urgent care facility would not have the specialists or equipment required for either procedure. Only hospital emergency rooms have the professional resources to immediately diagnose and treat time-sensitive health crises.
Which Urgent Care Facilities Can You Visit With Medicare?
For Medicare to cover urgent care, you must visit a facility accepting Medicare assignment. You can confirm your preferred care center’s eligibility in advance by checking Medicare’s online find-and-compare tool. Over 4,000 Medicare-certified hospitals exist nationwide, and almost all doctors and urgent care centers accept Medicare assignment.
However, if you receive care at a non-Medicare-approved facility, they can legally charge up to 15% more than the conventional Medicare-approved amount for service. Or, they can refuse Medicare payment altogether, leaving you to front all service costs out of pocket. Luckily, Medicare allows members to file reimbursement claims for a portion of any medical fees assessed at non-participating clinics.
How Much Does Urgent Care Cost With Medicare?
The average national cost of an urgent care visit before insurance is $209. Because Medicare Part B covers 80% of all eligible doctors’ services, average out-of-pocket costs would come down to a $42 coinsurance. Unless previously met in the same calendar year, Medicare members must also pay their $226 Part B deductible before coverage may commence.
If you have Medigap, eight of the ten available plans cover 100% of your outstanding coinsurance. Some others will even cover your deductible in full. If you received care from a non-Medicare-approved facility and they refuse to bill Medicare, you must pay the total charges out of pocket before requesting an official Medicare reimbursement.
Cost | |
|---|---|
Cost for Visit | ~$209 billed to Medicare |
Deductible | $226 |
Coinsurance | ~$42 |
Cost of Prescriptions | |
Medigap Contributions | ~$21 to $318, depending on your plan type and deductible |
What Other Expenses Are Incurred Using Urgent Care?
Depending on the injury or illness sustained and its aftermath, the professionals at your urgent care center may bill Medicare for additional expenses such as prescription drugs or durable medical equipment (DME) necessary in managing your recovery. Medicare covers DME and prescribed medications from urgent care centers identically as it would at other medical facilities.
For example, if you get treated for a minor fracture, Medicare Part B would cover 80% of an assistive cane as medically necessary DME. Or, if you needed antibiotics or pain medication, your Medicare Part D plan would pay its contractual portion of your prescription costs. Notably, however, beneficiaries without Part D would have to pay for prescription drugs entirely out of pocket.
How To Get Your Urgent Care Visit Covered By Medicare
Follow these steps to secure Medicare coverage for any necessary urgent care visit:
- Review your plan: Contact your Medicare agent to clarify your urgent care eligibility and cost-sharing responsibilities. Coverage will vary depending on whether you have Original Medicare, Medicare Part D, Medigap, or Medicare Advantage.
- Determine the severity of your condition: Urgent care facilities provide same-day medical attention for unexpected minor ailments or injuries. If you have experienced a life-threatening or permanently life-altering trauma, go to the ER instead.
- Find an urgent care clinic that accepts Medicare assignment: Use the find-and-compare tool on Medicare’s website to ensure you qualify for coverage at your preferred location.
- Receive care and pay your portion of costs: After treatment, your doctors may prescribe follow-up care and bill Medicare accordingly. Prepare to pay your 20% coinsurance and any other subsequent prescription costs.
- File a reimbursement claim, if necessary: If you went to a non-Medicare-approved urgent care center, you can request partial reimbursement for any out-of-pocket charges within 12 months of receiving service.
Should You Visit Urgent Care With Medicare?
Yes, if you have Original Medicare or Medicare Advantage and need same-day medical attention for a minor injury or condition, find a Medicare-approved urgent care center and receive treatment. After meeting your annual Part B deductible, you’ll only have a 20% coinsurance for the service.
Medicare-covered urgent care costs a fraction of what similar services would cost at the emergency room, allowing you to address concerning issues before they worsen and become serious health risks. However, if you believe your condition could cost you your life, use of any limbs, or lead to severe organ or brain damage, forego urgent care and go straight to the ER.
Advantages
Visiting urgent care as a Medicare recipient offers many benefits:
- Wide network of facilities: Most urgent care facilities nationwide accept Medicare.
- Immediate treatment: Urgent care provides immediate treatment for concerning but nonemergency health issues, such as minor burns and sprains, before they have time to worsen.
- Professional staff: Urgent care facilities have professional doctors, assistants, and nurses on staff.
- Diagnostic and preventative services: Many urgent care centers have access to a limited number of other Medicare-covered diagnostic and preventative care services like X-rays and vaccines.
- Affordable: Urgent care visits cost exponentially less than hospital care.
- Quick service: Urgent care centers generally have shorter wait times than emergency rooms.
- Ability to request reimbursement: Even if you have to pay out of pocket at a non-participating clinic, you can formally request reimbursement from Medicare.
Disadvantages
However, before driving to your local facility, consider the following drawbacks of Medicare-covered urgent care:
- Must attend a Medicare-approved facility: If you receive care at a non-Medicare-approved facility, you may have to front the total cost of service out of pocket.
- Lack of advanced resources: Urgent care centers do not have advanced medical resources, such as CT scans or on-site labs, to perform complicated and timely diagnostic tests.
- No specialists on-site: Urgent care facilities do not have the specialists, surgeons, or necessary equipment to treat life-threatening conditions like cardiac arrest, major head trauma, or respiratory failure.
- Limited access: Medicare Advantage recipients often must stick within a closed network of healthcare facilities, further limiting their access to urgent care coverage.
Final Thoughts
If you have a nagging injury, minor wound, or moderate health condition and cannot secure a timely appointment with your PCP, urgent care would provide immediate medical attention at the same Medicare-covered rates. Most urgent care centers nationwide accept Medicare, leaving beneficiaries to pay only their 20% Part B coinsurance after meeting their Part B deductible.
Remember that urgent care professionals can only attend to unexpected, albeit minor, injuries and illnesses like low fevers, sprained ankles, cuts, burns, vomiting, and bacterial infections. If you have any doubt about your condition’s severity or believe your life is at stake, bypass urgent care and go straight to the emergency room.