emergency room visit cost with medicare

Does Medicare cover emergency room visits?

Published by Medicare Made Clear®

Yes, Medicare covers emergency room visits for injuries, sudden illnesses or an illness that gets worse quickly. Specifically, Medicare Part B will cover ER visits. And, since emergencies may occur anytime and anywhere, Medicare coverage for ER visits applies to any ER or hospital in the country. Note though, Medicare only covers emergency services in foreign countries in select situations.

How much does an ER visit cost?

Medicare typically charges a copay for each emergency room visit and copays for hospital services you receive during the visit. In addition to these copays, you will pay a coinsurance for doctor services you receive in the ER. Medicare Part B typically pays 80 percent of the Medicare-approved amount for doctor services, and you are responsible for the remaining 20 percent of the cost. The Part B deductible also applies.

The total amount you actually pay for an ER visit will depend on the type of facility you go to, whether you have other insurance, such as a Medicare supplement plan (Medigap) or a Medicare Advantage plan (Part C), and other factors.

Costs can change if you are admitted to the hospital

If an ER visit results in being you admitted to the hospital, then the visit is considered part of an inpatient stay and ER-related copays would not apply. To qualify as such, a hospital admission must happen within three days of the ER visit for the same or a related condition, and it must be at the hospital where ER services were provided. Admission to a different hospital within three days, even for the same condition, would be considered a separate event.

Does Medicare Advantage cover ER visits?

Medicare Advantage plans cover ER visits – and everything else that Original Medicare (Parts A & B) covers. By law, these plans must offer coverage equal to or better than what Original Medicare provides. So, though Medicare Advantage plans typically have provider networks, they must cover emergency care from both network and out-of-network providers. In other words, Medicare Advantage plans cover ER visits anywhere in the U.S.

Each Medicare Advantage plan sets its own cost terms for ER visits and other covered services. For example, you may pay copays or coinsurance for an ER visit and for services you receive while in the ER. Some plans also have deductibles. It’s important to check each plan’s details for information about coverage for ER visits.

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How does Medicare cover emergency room costs?

Kimberly Lankford,

The type of Medicare you have determines how it pays for emergency department services.

Original Medicare covers emergency services under Medicare Part B at any U.S. hospital or medical facility that accepts Medicare. However, that care is subject to a deductible and 20 percent copayment. Supplemental insurance, such as a Medigap policy or a retiree plan from your former employer, may cover these out-of-pocket expenses.

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Medicare defines an emergency as an injury, sudden illness or an illness that gets much worse.

If you’re admitted to the same hospital for a related condition within three days, you won’t have to pay the copayment because the visit is considered part of your inpatient hospital stay, covered through Medicare Part A . 

Medicare Part B also covers urgent care visits needed to treat a sudden illness or injury that isn’t a medical emergency. Urgent care visits are also subject to a deductible and 20 percent copayment.

How does Medicare Advantage cover emergency services?

Medicare Advantage plans typically have provider networks and generally charge higher copayments and deductibles or don’t cover out-of-network care at all. But the rules are different for emergency services.  

In this case, Medicare Advantage plans must cover emergency care as an in-network service, even if the hospital or facility isn’t in the provider’s network. But copayments may be different from under original Medicare.  

For example, you may need to pay as much as a $135 copayment for each emergency room visit, whether it’s at an in-network or out-of-network facility. You can compare emergency care copayments for each Medicare Advantage plan in your area using the Medicare Plan Finder . Click on the Plan Details blue button at the bottom of an Advantage plan’s description.

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A different definition of emergencies. For Advantage plans, the Centers for Medicare & Medicaid Services (CMS) considers an emergency medical condition one that, if not treated, could result in:

• Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child. ​​
• Serious impairment to bodily functions.
• Serious dysfunction of any bodily organ or part.

Your emergency medical condition status is not affected if a later medical review found no actual emergency, CMS says. The plan can’t require prior authorization for emergency services.  

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With some MA plans, if you’re admitted to the hospital within 24 hours, you may not need to pay the copayment for the emergency room visit. Instead, it becomes part of your hospital stay.

How to find the details. Specifics vary by plan. See the plan summary on the website of each private plan or evidence of coverage. You can get to these documents through Medicare’s Plan Finder even if you’re not shopping for new coverage.

Log in if you have an account to see a summary of your current coverage. Or navigate through the Plan Finder by entering your zip code, choosing your coverage year, hitting the Continue button, clicking Medicare Advantage Plan (Part C) , tapping the Find Plans button and going though the questions. You don’t need to compare your drug costs, but you do want to get to the list of plans for your area and find your specific plan.

Click the Plan Details button, and on the next page the Plan website link. From there, your provider’s website will walk you through steps to learn information about your plan on its website. You’ll generally see a link to View plan summary or View plan documents within the plan information. Both documents are very detailed but often let you search within for “emergency” so you can find what’s relevant to your situation.

Urgent care also possible. Your Medicare Advantage plan may cover urgent care visits from out-of-network providers. These are nonemergency situations that require immediate medical attention when a network provider is not available, such as when you have a severe sore throat on a weekend and your doctor is off or if you’re traveling outside the plan’s service area.

You’ll have the same copayment as in-network urgent care, which could be around $50. 

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How does Medicare cover emergency ambulance services?

Medicare Part B covers emergency ambulance services , but they’re subject to a deductible and 20 percent coinsurance. A supplemental policy should help cover those.

Part B will pay for ambulance transportation to a hospital or skilled nursing facility if traveling in any other vehicle could endanger your health. This applies to emergency transport in an airplane or helicopter if you need immediate and rapid transport that a ground service can’t provide.

Medicare Advantage, too, covers emergency ambulance services, but like its emergency room coverage, its copay rates can be high. You may have a $300 copay for each one-way trip. See the plan’s evidence of coverage for details. 

Keep in mind

Medicare covers emergency room visits throughout the United States, but it typically doesn’t cover emergency care outside the U.S., except in limited circumstances .  

Some Medigap policies cover foreign travel emergency care with a lifetime limit of $50,000. Some Medicare Advantage plans provide limited coverage for foreign travel emergencies. Specifics vary a lot by plan.

Another option is buying travel insurance , which may provide more coverage for emergency care and medical evacuation when traveling. 

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Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at  Kiplinger’s Personal Finance  and has written for  The Washington Post  and  Boston Globe . She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.

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How Much Does an ER Visit Cost? Free Local Cost Calculator 

It’s true that you can’t plan for a medical emergency, but that doesn’t mean you have to be surprised when it’s time to pay your hospital bill. In 2021, the U.S. government enacted price transparency rules for hospitals in order to demystify health care costs. That means it should be easier to get answers to questions like how much an ER visit costs.

While the question seems pretty straightforward, the answer is more complicated. Your cost will vary based on factors such as if you’re insured, whether you’ve met your deductible, the type of plan you have, and what your plan covers. 

There is a lot to consider. This guide will take you through specific scenarios and answer questions about insurance plans, deductibles, co-payments, and discuss scenarios such as how much it costs if you go to the ER when it isn’t an emergency. 

You’ll learn a few industry secrets too. Did you know that if you don’t have insurance you might see a higher bill? According to the Wall Street Journal , it’s common for hospitals to charge uninsured and self-pay patients higher rates than insured patients for the same services. So, where can you go if you can’t afford to go to the ER?

Keep reading for all this plus real-life examples and cost-saving tips.

How Much Does an ER Visit Cost Without Insurance?

Everything is more expensive in the ER. According to UnitedHealth, a trip to the emergency department can cost 12 times more than a typical doctor’s office visit. The average ER visit is $2,200, and doesn’t include procedures or medications. 

If you want to get a better idea of what an ER visit will cost in your area, check out our medical price comparison tool that analyzes data from thousands of hospitals.

Compare Procedure Costs Near You

Other out-of-pocket expenses you may incur include bills from third parties. A growing number of emergency departments in the United States have become business entities separate from the hospital. So, third-party providers may bill you too, like:

• EMS services, like an ambulance or helicopter 
• ER physicians
• Attending physician
• Consulting physicians
• Advanced practice nurses (CRNA, NP)
• Physician assistants (PA)
• Physical therapists (PT)

And if your insurance company fails to pay, you may have to pay these expenses out-of-pocket.

How Much Does an ER Visit Cost With Insurance? 

The easiest way to estimate out-of-pocket expenses for an ER visit (or any other health care service) is to read your insurance policy. You’ll want to look for information around these terms:

• Deductible: The amount you have to pay out-of-pocket before your insurance kicks in . 
• Copay: A set fee you pay upfront before a covered medical service or procedure. 
• Coinsurance: The percentage you pay for a service or a procedure once you’ve met the deductible.
• Out-of-pocket maximum: The most you will pay for covered services in a rolling year. Once met, your insurance company will pay 100% of covered expenses for the rest of the year. 

Closely related to out-of-pocket expenses like deductibles and co-insurance are premiums. A premium is the monthly fee you (or your sponsor) pay to the insurance company for coverage. If you pay a higher premium, you’ll have a lower deductible and fewer out-of-pocket costs whenever you use your insurance to pay for services such as a visit to the ER. The opposite is also true — high deductible health plans (HDHP) offer lower monthly payments but much higher deductibles. 

Sample ER Visit Cost

Using a few examples from plans available on the Marketplace on Healthcare.gov (current as of November 2021), here’s how this might play out in real life:

Rob is a young, healthy, single guy. He knows he needs health insurance but he feels reasonably sure that the only time he’d ever use it is in case of an emergency. Here’s the plan he chooses:

Plan: Blue Cross/Blue Shield Bronze Monthly premium: $394 Deductible: $7,000 Out-of-pocket maximum: $7,000 ER coverage: 100% after meeting the deductible

Rob does the math and considers the worst case scenario. If he does go to the ER, he’ll pay full price if he hasn’t yet met his deductible. But since both his deductible and his maximum out-of-pocket are the same, $7,000 is the most he’ll have to pay before his insurance kicks in at 100%.

Now imagine that Rob gets married and is about to start a family. He might need a different insurance plan to account for more hospital bills, doctors appointments, and inevitable emergency room visits.

Since Rob knows he’ll be using his insurance more often, he picks a plan with a lower deductible that covers more things. 

Plan: Bright HealthCare Gold Monthly premium: $643 Deductible: $0 Out-of-pocket maximum: $6,500 ER coverage: $500 Vision: $0 Generic prescription: $0 Primary care: $0 Specialist: $40

This time Rob goes with a zero deductible plan with a higher monthly premium. It’s more out-of-pocket each month, but since his plan covers doctor’s visits, prescription drugs, and vision, he feels more prepared as his lifestyle shifts into family mode. 

If he has to go to the ER for any reason, all he’ll pay is $500 and his insurance pays the rest. And worse case scenario, the most he’ll pay out-of-pocket in a year is $6,500. 

How Much Does an ER Visit Cost if You Have Medicare?

Medicare Part A only covers an emergency room visit if you’re admitted to the hospital. Medicare Part B covers 100% of most ER costs for most injuries, or if you become suddenly ill. Unlike private insurance and insurance purchased on the Affordable Care Act (ACA) Marketplace, Medicare rarely covers ER visits that happen while you’re outside of the United States.

To learn more, read: How to Use the Healthcare Marketplace to Buy Insurance

How Much Does an ER Visit Cost for Non-Emergencies?

When you have a sick child but lack insurance, haven’t met your deductible, or if you’re between paychecks, just knowing you can go to the ER without being hassled for money feels like such a relief. ER staff won’t demand payment upfront, and they usually don’t ask about insurance or assess your ability to pay until after discharge.

There are other reasons, too. You might be tempted to go to the ER for situations that are less than emergent because emergency departments provide easy access to health services 24/7, including holidays and the odd hours when your primary care physician isn’t available. If you’re one of the 61 million Americans who are uninsured or underinsured , you might go to the ER because you don’t know where else to go.

What you may not understand is the cost of an ER visit without insurance can total thousands of dollars. Consumers with ER bills that get sent to collections face some of the most aggressive debt collection practices of any industry. Collection accounts and charge-offs could affect your credit score for the better part of a decade.

Did you know that charges begin racking up as soon as you give the clerk your name and Social Security number? There are tons of horror stories out there about people receiving medical bills after waiting, some for many hours, and leaving without treatment. 

4 ER Alternatives Ranked by Level of Care

First and foremost, if you’re experiencing a medical emergency, call 911 or go to the closest emergency room. Do not rely on this or any other website for advice or communication. 

If you’re not sure whether your condition warrants immediate, high-level emergency care, you can always call your local ER and ask to speak to their triage nurse. They can quickly assess how urgent the situation is. 

If you are looking for a lower-cost alternative to the ER, this list provides a few options. Each option is ranked by their ability to provide you with a certain level of care from emergent care to the lowest level, which is similar to the routine care you would receive at a doctor’s office. 

1. Charitable Hospitals  

There are around 1,400 charity hospitals , clinics, and pharmacies dedicated to serving low-income families, including the uninsured. Most charitable, not-for-profit medical centers provide emergency room services, making it a good option if you’re uninsured and worried about accruing substantial medical debt. 

ERs at charitable hospitals provide the same type of medical care for conditions like trauma, broken bones, and life-threatening issues like chest pain and difficulty breathing. The major difference is the price tag. Emergency room fees at a charity hospital are usually flexible and almost always based on your income. 

2. Urgent Care Centers

Urgent care centers are free-standing facilities designed to treat patients with serious but not life-threatening conditions. Also called “doc in a box,” these ambulatory care centers are a good choice for treating stable but chronic health issues, fever, urinary tract infections, back pain, abdominal pain, and moderately high blood pressure, to name a few. 

Urgent care clinics usually have a medical doctor on-site. Some clinics offer point-of-care diagnostic tests like ultrasound and X-rays, as well as basic lab work. The average cost for an urgent care visit is around $180, according to UnitedHealth.

3. Retail Health Clinics

You may have noticed small retail health clinics (RHC) popping up in national drugstore chains like CVS, Walgreens, and in big-box stores like Target and Walmart. The Little Clinic is an example of an RHC that offers walk-in health care services at 190 supermarkets across the United States. 

RHCs help low-acuity patients with minor medical problems like sore throat, cough, flu-like symptoms, and other conditions normally treated in a doctor’s office. If you think you’ll need lab tests or other procedures, an RHC may not be the best choice. Data from UnitedHealth puts the average cost for an RHC visit at $100.

4. Telehealth Visits

Telehealth, in some form, has been around for decades. Until recently, it was mostly used to provide access to care for patients living in the most remote or rural areas. Since 2020, telehealth visits over the phone, via chat, or through videoconferencing have become a legitimate and extremely cost-effective alternative to in-person office visits. 

Telehealth is perfect for some types of mental health therapies, follow-up appointments, and triage. For self-pay, a telehealth visit only costs around $50, according to UnitedHealth.

Tips for Taking Control of Your Health Care

• Don’t procrastinate. Delaying the care you need for too long will end up costing you more in the end. 
• Switch your focus from reactive care to proactive care. Figuring out how to pay for an ER visit is a lot harder (and costlier) than preventing an ER visit in the first place. Data show that preventive health care measures lead to fewer illnesses and better outcomes.
• Plan for the unknown. It’s inevitable that at some point in your life you’ll need health care. Start a savings account fund or better yet, enroll in a health savings account (HSA). If you’re employed (even part-time) you already qualify for an HSA. A contribution of just $9 a paycheck could add up to $468 tax-free dollars for you to spend on health care every year. Unlike the use-it-or-lose-it savings plans of the past, modern plans don’t expire. You can use HSA dollars to pay for out-of-pocket costs like copayments, deductibles, and for services that your health insurance may not cover, like dental and vision services. 
• Advocate for yourself. There is nothing more empowering than taking charge of your health. Shop around for services and compare prices on procedures to make sure you’re getting the best prices possible.
• If you are uninsured or doing self-pay, negotiate your bill and ask for a cash discount. 

Estimate the Cost of the ER Before You Need It

It’s stressful to think about money when you’re facing an emergency. Research the costs of your nearest ER before you actually need to go with Compare.com’s procedure cost comparison tool . 

All you have to do is enter your ZIP code and you’ll immediately see out-of-pocket costs for ER visits at your local emergency rooms. It works for other medical services too, like MRIs, routine screenings, outpatient procedures, and more. Find the treatment you need at a price you can afford.

Disclaimer: Compare.com does not offer medical advice and is in no way a substitute for any medical advice received from health professionals. Compare.com is unable to offer any advice on any medical procedure you may need.

Nick Versaw leads Compare.com's editorial department, where he and his team specialize in crafting helpful, easy-to-understand content about car insurance and other related topics. With nearly a decade of experience writing and editing insurance and personal finance articles, his work has helped readers discover substantial savings on necessary expenses, including insurance, transportation, health care, and more.

As an award-winning writer, Nick has seen his work published in countless renowned publications, such as the Washington Post, Los Angeles Times, and U.S. News & World Report. He graduated with Latin honors from Virginia Commonwealth University, where he earned his Bachelor's Degree in Digital Journalism.

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If you have Original Medicare , Part B covers emergency room services anywhere in the U.S. Medicare Advantage Plans also must cover emergency room services anywhere in the country. Emergency room services are typically provided when you have a medical condition that requires immediate action, such as an injury or sudden illness.

If you have a Medicare Advantage Plan, be aware that:

• Your plan cannot require you to see an in-network provider .
• You do not need 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 , Specifically, you will be billed either $50 or your plan’s in-network cost for emergency services, whichever is less.
• Your plan must cover medically necessary follow-up care related to the medical emergency if delaying care would endanger your health.
• You have the right to appeal if your plan does not cover your emergency care.

If your condition was not an emergency but appeared to be an emergency, 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 appeared to be an emergency.

Even if you do not have health insurance or the ability to pay, you still have the right under federal law to receive medical care in the case of an emergency.

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Does Medicare Cover Emergency Room Visits?

Written by: Rachael Zimlich, RN, BSN

Reviewed by: Selah Lee, Licensed Insurance Agent

Key Takeaways

Original Medicare Original Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). will cover at least a portion of your visit to the emergency room.

The part of Medicare that covers your visit will depend on if you are admitted or not.

If you are admitted to the hospital for at least two nights after an ER visit, Medicare Part A covers it.

If you are not admitted after an ER visit, Medicare Part B will cover it.

How Much Does Medicare Pay for an Emergency Room Visit?

Original Medicare will cover a portion of your visits to the emergency room, but whether or not you are admitted will determine if Part A or Part B coverage is used. In either case, you pay a portion of your cost for services, but Medicare pays the majority.

If you have a Medicare Advantage plan, your ER visit will be covered and the plan you choose will determine your out-of-pocket costs. You may also have to pay more for visiting doctors or facilities that are outside your plan’s network.

Does Medicare Part A or B Cover Emergency Room Visits?

Both Medicare Part A and B offer some coverage of emergency services depending on how long you need to stay in the hospital. If your ER visit leads to a hospital stay, Medicare Part A covers the costs, plus any services that were provided in the three days before your admission. If your visit is one where you are discharged from the emergency room or after just one night of observation, Medicare Part B will provide coverage.

Will Medicare Part A Cover Emergency Room Visits?

Medicare Part A only covers emergency room services when you are admitted by a doctor for at least two nights in the hospital. The “Two-Midnight” rule is important, because in some cases your doctor may just keep you one night for observation. These visits are considered outpatient care even though you spent the night in the hospital, and Medicare Part B will provide coverage.

Medicare Part B covers most emergency visits, especially if you are seen and sent home the same day, or spend one night for observation. Even if you are admitted, Part B will pay the portion of your bill that covers doctor’s services while Part A will pay inpatient hospital costs.

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Does Medicare Have a Copay for ER Visits?

Original Medicare does not have an established copay for emergency room visits. Instead, you will pay a share of the costs based on your Part A or Part B coverage, and which part of Medicare is applied to your visit.

If you are admitted for at least two nights after and ER visit and Part A is used, in 2024 you will pay:

• A $1,632 deductible for each inpatient stay for each benefit period. Benefit periods reset every 60 days you spend outside of a hospital or skilled nursing facility.
• If you were recently admitted and already paid this deductible for your benefit period, you will not have to pay it again for the same benefit period.
• Coinsurance applies, also, but only after 60 days of hospitalization.

If you visit the emergency room and are sent home right away or are admitted for just one night of observation, Part B coverage applies. This will cost you:

• Your annual deductible — $240 for 2024 — if you haven’t already met it for the year.
• Twenty percent of the remainder of the Medicare-approved costs associated with the visit.

How Much of a Hospital Bill Does Medicare Pay?

When Medicare Part A is applied for emergency department visits that turn into an inpatient stay, your costs will be covered after you pay your deductible and coinsurance.

When Medicare Part B is used for an ER visit where you are not admitted or kept only one night for observation, Medicare pays for 80% of the approved cost after your deductible is met.

Can I Get Help Paying?

If you need help paying for your share of your emergency department bill — regardless of whether Medicare Part A or B was applied — you may be able to use additional coverage if you’ve signed up for a Medicare supplement plan . Medicare supplement plans can only be purchased if you have Original Medicare (Parts A and B). If you have a Medicare Advantage plan, you will need to leave that policy.

Costs of Medicare supplement plans vary based on which plan you choose. Medicare supplement plans can be used to cover costs such as deductibles, copayments and coinsurance that are not covered by Original Medicare.

How Many ER Visits Does Medicare Cover?

There is no limit to how many ER visits Medicare covers, but you may have to start a new benefit period if it’s been awhile since your last admission. If you are admitted to the hospital and it’s been more than 60 days since your last admission, you will have to start a new benefit period and pay your Part A deductible. If you were admitted within the last 60 days, you will not have to pay this deductible again since you are in the same benefit period.

Find the Medicare Advantage plan that meets your needs.

Who Covers Ambulance Transportation?

Regardless of whether you are admitted or not following an ER visit, Medicare Part B is used to pay for ambulance services. If you’ve already met your Part B deductible for the year, you will be responsible for 20% of the cost of these services.

What About Medications?

Medications that you are given while admitted in the hospital are covered under Part A. If you are given a prescription in the emergency room and sent home, you will have to pay for this medication unless you have Medicare Part D coverage (prescription drug plans). Costs for prescription coverage vary based on the Medicare Part D plan you choose.

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Does Medicare Cover Emergency Room Visits?

• by Christian Worstell
• January 12, 2024
• Reviewed by John Krahnert

Yes, emergency room visits are typically covered by Medicare .

Most outpatient emergency room services are covered by Medicare Part B, and inpatient hospital stays are covered by Medicare Part A.

Medicare Advantage plans (Part C) also cover ER visits . Many Medicare Advantage plans also offer benefits not found in Original Medicare. 

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What Medicare Part A covers

Medicare Part A hospital insurance helps cover:

• Inpatient care in a hospital
• Skilled nursing facility care
• Hospice care
• Some home health care services

Medicare Part A is typically premium-free, as long as you or your spouse paid sufficient Medicare taxes while working.

If you go to the emergency room and are admitted as an inpatient , Medicare Part A helps cover some of the costs related to your hospital stay once your Part A deductible is met .

In 2024, the Medicare Part A deductible is $1,632 per benefit period .

What Medicare Part B covers

Medicare Part B is known as medical insurance and helps cover medically necessary services and preventive services, which can include:

• Doctor’s office visits
• Clinical research
• Ambulance services
• Durable medical equipment
• Mental health services

Medicare Part B may also cover services you receive when you visit the emergency room as an outpatient.

Medicare Part B is optional, and if you enroll in Part B you must also enroll in Part A. Unlike Medicare Part A, which is premium-free for most people, you must pay a monthly premium for Medicare Part B.

The standard Part B premium in 2024 is $174.70 per month.

Emergency room copayments and coinsurance

Even if your emergency room visit is covered by Medicare, you are typically responsible for paying a portion of the costs, known as copayments or coinsurance.

Typically, you pay a Medicare emergency room copayment for the visit itself and a copayment for each hospital service.

How you are charged depends on several factors, including which part of Medicare covers your visit (Medicare Part A, Medicare Part B or both) and whether or not you have met your Part A and Part B deductibles.

In 2024, the Part A deductible is $1,632 per benefit period, and the Part B deductible is $240 per year.

Medicare Part A coinsurance

Generally, if you go to the emergency room and are admitted as an inpatient, Medicare Part A will cover a portion of the costs, and in 2024 you pay:

• $0 coinsurance for each benefit period for days 1-60 spent in the hospital
• $408 coinsurance for days 61-90 in each benefit period
• $816 coinsurance per each “lifetime reserve day” beyond day 90 in each benefit period
• All costs beyond lifetime reserve days

Remember, you must meet your Part A deductible before Medicare will pay its share for covered services.

Medicare Part B copayments

If you go to the emergency room and receive care from a doctor but are not admitted as an inpatient, Medicare Part B will typically cover a portion of your medical costs.

After your Part B deductible is met, you typically pay 20 percent of the Medicare-approved amount for most services, and Medicare pays the rest.

Medicare Advantage plans cover emergency room visits

Medicare Advantage (Medicare Part C) is an alternative to Original Medicare (Medicare Part A and Part B) that provides the same hospital and medical benefits as Original Medicare. This means that Medicare Advantage plans, like Original Medicare, will cover at least some of your emergency room costs.

Most Medicare Advantage plans may also cover benefits not included in Medicare Part A or Part B. 

To learn more about Medicare Advantage plans that may be available in your area and to find out about the emergency room coverage they offer, speak with a licensed insurance agent today.

Explore Medicare Advantage plan benefits in your area

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About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at [email protected] .

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Will My Medicare Policy Cover a Visit to the ER?

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Part B of Original Medicare covers emergency visits since emergency room (ER) visits are considered outpatient care. Should your visit turn into a hospital admittance, Part A of your plan would cover your costs. Keep in mind you will still need to pay copays, coinsurance and deductibles.

Keep reading to see how the different parts of Medicare work together to cover your healthcare costs.

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How Much Does Medicare Cover for Emergency Room Visits?

What parts of medicare cover emergency room visits, does medicare have copays for hospital visits, how much is an emergency room visit without medicare.

Medicare covers ER visits after you've met your deductible, minus any copays or coinsurance costs. If you are admitted to the hospital for an inpatient stay following an ER visit, additional costs might apply.

Several parts of Medicare can play some role in covering your emergency room visit.

Medicare Part A

Part A (hospital insurance) of Original Medicare doesn't cover emergency room visits because the ER is considered outpatient care, not inpatient. However, should an ER visit lead to a hospital admission within three days of your initial visit, Part A will cover your treatment as the emergency room visit will be considered a part of your inpatient stay but only after you've met your $1,600 deductible . [1] Remember that between 2014 and 2017, 23% of ER visits led to hospitalizations for those 60 and up. [2]

Keep in mind, however, that you will have to pay your deductible over again for every pay period (60 days between receiving inpatient services). [1] This means you could pay multiple deductibles several times a year depending on how often you get inpatient care. Copays will also apply and can be as high as $800 depending on how long your stay is. [1]

Medicare Part B

Part B (medical insurance) is specifically designed to cover outpatient medical services, including emergency room visits. You will have to meet your yearly deductible of $226 as well as a 20% coinsurance . [1]

Additionally, you will pay a separate copay (typically 20% of covered services) for each Medicare-approved service you receive during your outpatient care. [1] If you are admitted to the same hospital for a related condition within three days of visiting the ER, you won't need to pay your copays as your visit will fall under inpatient care. [3]

Medicare Advantage

Also called Medicare Part C, Medicare Advantage plans provide Medicare coverage but the plans are issued by private insurance companies.

Similar to Original Medicare, Medicare Advantage plans must also cover emergency room visits. However, the copayments and other costs can differ, so it’s essential to consult your plan for details.

For instance, a Blue Cross Medicare Advantage Classic (PPO) plan can have a $90 copay for an ER visit while a CareFirst BlueCross BlueShield Advantage Core (HMO) plan can have a $95 copay. [4][5]

Medigap, or Medicare supplement insurance, can aid in covering the “gaps” in Original Medicare, such as copayments, deductibles and coinsurance. If you have a Medigap policy, it might cover some of the costs that Medicare Part B does not cover during an ER visit. You can enroll in Medigap once you have Original Medicare.

Original Medicare will typically require you to pay a copayment when visiting the emergency room. The copay amount can vary widely based on your coverage and the nature of the medical services received. For instance, Part A breaks down hospital copays as follows: [1]

• Days 1-60: $0 after your deductible is met
• Days 61-90: $400 every day
• Days 91-150: $800 every day while using your 60 lifetime reserve days
• After day 150: You pay all costs

Without Medicare coverage, the cost of an emergency room visit can be exorbitant with prices being $2,600 or higher depending on the provider. [6] Additional costs can be incurred for tests, treatments and if hospital admission is necessary.

How long can you stay at the hospital with Medicare?

Medicare Part A covers up to 60 days of inpatient hospital care for each benefit period after the beneficiary has met the Part A deductible. [7] Beyond 60 days, additional costs apply.

What is the Medicare deductible for an emergency room visit?

For emergency room visits under Medicare Part B, you'll generally need to meet the annual Part B deductible of $226 for this year. [1] Amounts can change yearly.

Does Medicare pay for emergencies?

Medicare does provide coverage for emergency situations, including emergency room visits, under Part B as well as if you have a Medicare Advantage plan.

Does Medicare cover ambulance rides?

Medicare Part B may cover ambulance services to or from a hospital or a skilled nursing facility when other transportation could endanger your health. However, you are typically responsible for 20% of the Medicare-approved amount. [8]

Will Medicare pay if I visit the ER twice on the same day?

Medicare Part B has a limitation on covering multiple visits in a single day; it will only cover two visits if they are for distinct, unrelated reasons. If a return visit occurs on the same day for an identical condition, the subsequent visit will not be eligible for coverage.

• Medicare.gov. “ Costs .” Accessed September 1, 2023.
• National Institutes of Health. “ Emergency Department Increased Use of Observation Care for Elderly Medicare Patients .” Accessed September 1, 2023.
• Medicare.gov. “ Emergency Department Services .” Accessed September 1, 2023.
• BlueCross BlueShield of New Mexico. “ Summary of Benefits ,” Page 6. Accessed September 1, 2023.
• UnitedHealthcare. “ What Are My Care Options and Their Costs? ” Accessed September 1, 2023.
• CareFirst “ Summary of Benefits ,” Page 4. Accessed September 1, 2023.
• Medicare.gov. “ Inpatient Hospital Care .” Accessed September 1, 2023.
• Medicare.gov. “ Ambulance Services .” Accessed September 1, 2023.
• Insurance quotes / 
• Medicare / 
• Does Medicare Cover Emergency Room Visits

Derek is a former staff writer and has written 100+ articles on property & casualty, health and life insurance topics as an insurance expert for SmartFinancial. Within his decade-long career writing about finances, entertainment, religion and philosophy, Derek spent three years writing financial articles for credit unions throughout the U.S. He prides himself on his ability to translate complex topics into actionable tips for everyday people.

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• An emergency room visit typically is covered by health insurance. For patients covered by health insurance, out-of-pocket cost for an emergency room visit typically consists of a copay, usually $50-$150 or more, which often is waived if the patient is admitted to the hospital. Depending on the plan, costs might include coinsurance of 10% to 50%.
• For patients without health insurance, an emergency room visit typically costs from $150-$3,000 or more, depending on the severity of the condition and what diagnostic tests and treatment are performed. In some cases, especially where critical care is required and/or a procedure or surgery is performed, the cost could reach $20,000 or more. For example, at Park Nicollet Methodist Hospital in Minnesota, a low-level emergency room visit, such as for a minor laceration, a skin rash or a minor viral infection, costs about $150 ; a moderate-level visit, such as for a urinary tract infection with fever or a head injury without neurological symptoms, about $400 ; and a high-level visit, such as for chest pains that require multiple diagnostic tests or treatments, or severe burns or ingestion of a toxic substance, about $1,000, not including the doctor fees. At Dartmouth-Hitchcock Medical Center[ 1 ] , a low-level emergency room visit costs about $220, including hospital charge and doctor fee, with the uninsured discount, while a moderate-level visit costs about $610 and a high-level visit about $1,400 .
• Services, diagnostic tests and laboratory fees add to the final bill. For example, Wooster Community Hospital, in Ohio, charges about $170 for a simple suture, $200 for a complex suture, about $170 for a minor procedure and about $400 for a major procedure, not including doctor fees, medicine or supplies.
• A doctor fee could add hundreds or thousands of dollars to the final cost. For example, at Grand Lake Health System[ 2 ] in Ohio, an emergency room doctor charges about $100 for basic care, such as a wound recheck or simple laceration repair; about $300 for mid-level care, such as treatment of a simple fracture; about $870 for advanced-level care, such as frequent monitoring of vital signs and ordering multiple diagnostic tests, administering sedation or a blood transfusion for a seriously injured or ill patient; and about $1,450 for critical care, such as major trauma care or major burn care that could include chest tube insertion and management of IV medications and ventilator for a patient with a complex, life-threatening condition. At the Kettering Health Network, in Ohio, a low-level visit costs about $350, a high-level visit costs about $2,000 and critical care costs almost $1,700 for the first hour and $460 for each additional half hour; ER procedures or surgeries cost $460-$2,300 .
• According to the U.S. Agency for Healthcare Research and Quality[ 3 ] the average emergency room expense in 2008 was $1,265 .
• According to the U.S. Centers for Disease Control and Prevention, in 2008, about 18%of emergency room patients waited less than 15 minutes to see a doctor, about 37%waited 15 minutes to an hour, about 15% waited one to two hours, about 5% waited two to three hours, about 2% waited three to four hours, and about 1.5% waited four to six hours.
• In some cases, the doctor might recommend the patient be admitted to the hospital. The American College of Emergency Physicians Foundation offers a guide[ 4 ] on what to expect.
• An ambulance ride typically costs $400-$1,200 or more, depending on the location and services performed.
• An urgent care center offers substantial savings for more minor ailments. DukeHealth.org offers a guide[ 5 ] on when to seek urgent care. An urgent care visit typically costs between 20% and 50% of the cost of an emergency room visit. MainStreetMedica.com offers a cost-comparison tool for common ailments.
• Hospitals often offer discounts of up to 50% or more for self-pay/uninsured emergency room patients. For example, Ventura County Medical Center[ 6 ] in California offers ER visits, including the doctor fee and emergency room fee but not including lab tests, X-rays or procedures, for $150 for patients up to 200% of the federal poverty level, for $225 for patients between 200% and 500% of the federal poverty level and $350 for patients from 500% to 700% of the federal poverty level.
• The American College of Emergency Physicians Foundation offers a primer[ 7 ] on when to go to the emergency room.
• In most cases, it is recommended to go to the nearest emergency room. The U.S. Department of Health and Human Services offers a hospital-comparison tool[ 8 ] that lists hospitals near a chosen zip code.
•   patients.dartmouth-hitchcock.org/billing_questions/out_of_pocket_estimator_dhmc.ht...
•   www.grandlakehealth.org/index.php?option=com_content&view=article&id=106&Itemid=60
•   meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPS...
•   www.EmergencyCareforYou.org/VitalCareMagazine/ER101/Default.aspx?id=1288
•   www.dukehealth.org/health_library/health_articles/wheretogo
•   resources.vchca.org/documents/SELF%20PAY%20DISCOUNT%20GRID%20-%20BOARD%20LETTER%20...
•   www.EmergencyCareforYou.org/YourHealth/AboutEmergencies/Default.aspx?id=26018
•   www.medicare.gov/hospitalcompare/(S(efntd2saaeir2l5pgarwuvvg))/search.aspx?AspxAut...

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Medicare emergency room copay.

Original Medicare pays for emergency room visits, but there is usually a copay for emergency room visits that the beneficiary needs to pay. 

by Christian Worstell | Published October 25, 2023 | Reviewed by John Krahnert

Original Medicare is a federal health insurance program for seniors and people with certain disabilities. So does Medicare cover emergency room visits? When a Medicare recipient requires emergency care, Medicare does cover emergency room visits for the most part, and the recipient  pays a copayment .

Read on to learn more about emergency room costs and how a Medicare Supplement Insurance plan can help reduce what you pay out of pocket for Medicare emergency room coverage.

What is the Copay for Medicare Emergency Room Coverage?

A copay is the fixed amount that you pay for covered health services after your deductible is met. In most cases, a copay is required for doctor’s visits, hospital outpatient visits, doctor’s and hospital outpatients services, and prescription drugs. Medicare copays differ from coinsurance  in that they're usually a specific amount, rather than a percentage of the total cost of your care. 

Medicare does cover emergency room visits. You'll pay a Medicare emergency room copay for the visit itself and a copay for each hospital service. It is important to remember, however, that your  actual Medicare urgent care copay amount  can vary widely, depending on the services you require and where you receive care.

If you are admitted for inpatient hospital services after an emergency room visit, Medicare Part A does help cover costs for your hospital stay. Medicare Part A does not cover emergency room visits that don't result in admission for an inpatient hospital stay.

What Does Medicare Pay for Emergency Room Visits? 

Medicare Part A emergency room coverage is specifically for inpatient hospital stays. If your emergency room visit requires you to be admitted for inpatient care, your Medicare Part A benefits would kick in but are subject to the Part A deductible and coinsurance.

Most ER services are considered hospital outpatient services, which are covered by Medicare Part B .   They include, but are not limited to:

• Emergency and observation services, including overnight stays in a hospital
• Diagnostic and laboratory tests
• X-rays and other radiology services
• Some medically necessary surgical procedures
• Medical supplies and equipment, like splints, crutches and casts
• Preventive and screening services
• Certain drugs that you wouldn't administer yourself

NOTE: There's an important distinction to be made between inpatient and outpatient hospital statuses. Your hospital status affects how much you pay for services. Unless your doctor has written an order to admit you as an inpatient, you're an outpatient, even if you spend the night in the hospital.

How Medicare Part B Pays For Outpatient Services 

Medicare Part B pays for outpatient services like the ones listed above, under the Outpatient Prospective Payment System  (OPPS). The OPPS   pays hospitals a set amount of money (or payment rate) for the services they provide to Medicare beneficiaries.

The payment rate varies from hospital to hospital based on the costs associated with providing services in that area, and are adjusted for geographic wage variations.  

Other Medicare Costs

Aside from Medicare ER copays, there are other outpatient hospital costs that you should be aware of when visiting the emergency room, such as  deductibles  and  coinsurance . In most cases, if you receive care in a hospital emergency department and are covered by Medicare Part B, you'll also be responsible for: 

• An annual Part B deductible of $240 (in 2024).
• A coinsurance payment of 20% of the Medicare-approved amount for most doctor’s services and medical equipment.

How You Pay For Outpatient Services

In order for your Medicare Part B coverage to kick in, you must pay the yearly Part B deductible. Once your deductible is met, Medicare pays its share and you pay yours in the form of a copay or coinsurance.

Get Help Covering Your Emergency Room Copay

If you're worried about a trip to the emergency room adding expensive and unpredictable costs to your health care budget, consider joining a  Medicare Supplement Insurance (or Medigap) Plan .

Medigap is private health insurance that Medicare beneficiaries can buy to cover costs that Medicare doesn't, including some copays. All Medigap plans cover at least a percentage of your Medicare Part B coinsurance or ER copay costs. 

To find a Medigap plan in your area, call 1-800-995-4219 to connect with a licensed insurance agent.

Does medicare part a cover emergency room visits.

If you opted out of Medicare Part B, and only have Part A, you may be wondering if you can get coverage for an emergency room visit. Medicare Part A is designed for hospital insurance, meaning that it's benefits are generally used once admitted to the hospital. If your emergency room visit results in an inpatient admission, your Medicare Part A coverage would then kick in. 

How Much is an Emergency Room Visit?

The average cost of an emergency room visit is around $1,150, although the average cost of an emergency room visit for those age 65 and over is just $849. ¹

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About the author

Christian Worstell   is a licensed insurance agent and a Senior Staff Writer for MedicareSupplement.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.

His work has been featured in outlets such as   Vox ,   MSN , and   The Washington Post , and he is a frequent contributor to health care and finance blogs.

Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, NC.

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Emergency Room Visit: When to Go, What to Expect, Wait Times, and Cost

Knowing when and why to go for an emergency room visit can help you plan for care in the event of a medical emergency.

How much does it cost to go to an emergency room?

Emergency Room (ER) costs can vary greatly depending on what type of medical care you need. How much you pay for the visit depends on your health insurance plan. Most health plans may require you to pay something out-of-pocket for an emergency room visit. A visit to the ER may cost more if you have a High-Deductible Health Plan (HDHP) and you have not met your plan’s annual deductible. HDHP's typically offer lower monthly premiums and higher deductibles than traditional health plans. Your plan will start paying for eligible medical expenses once you’ve met the plan’s annual deductible. Here are some tips to pay less out of pocket .

When should I go to an emergency room?

Emergency rooms are often very busy because many people don’t know what type of care they need, so they immediately go to the ER when they are sick or hurt. You should make an emergency room visit for any condition that’s considered life-threatening.

Life-threatening conditions include, but are not limited to, things like a serious allergic reaction, trouble breathing or speaking, disorientation, a loss of consciousness, or any physical trauma.

If you need to be treated for problems that are considered non-life threatening, such as an earache, fever and flu symptoms, minor animal bites, mild asthma, or a mild urinary tract infection, consider seeing your doctor or visiting an urgent care center or convenience care clinic.

What is the cost of an emergency room visit without insurance?

Emergency room costs with or without health insurance can be very high. If you have health insurance, review your plan documents for details on the costs associated with your plan, including your plan deductible, coinsurance, and copay requirements.

If you don’t have insurance, you may be required to pay the full cost of your treatment, which can vary by facility and the type of treatment required. Always plan ahead for sudden sickness, injury, or other medical needs, so you know where to go and how much it could cost. If you need medical care, but it’s not life-threatening you may not have to go to the ER—there are other more affordable options:

• Urgent care center: Staffed by doctors, nurses, and other medical staff who can treat things like earaches, urinary tract infections, minor cuts, nausea, vomiting, etc. Wait times may be shorter and using an urgent care center could save you hundreds of dollars when compared to an ER.
• Convenience care clinic: Walk-in clinics are typically located in a pharmacy (CVS, Walgreens, etc.) or supermarket/retail store (Target, Walmart, etc.). These clinics are staffed with physician assistants and nurse practitioners who can provide care for minor cold, fever, flu, rashes and bruises, head lice, allergies, sinus/ear infections, urinary tract infections, even flu and shingles shots. No appointments are needed, wait times are usually minimal, and a convenience care clinic costs much less than an ER.

Plan ahead for when you need medical care. You may not need an emergency room visit and the bill that could come with it.

What are common emergency room wait times?

Emergency room wait times vary according to hospital and location. Patients in the ER are seen based on how serious their condition is. This means that the patients with life-threatening conditions are treated first, and those with non-life threatening conditions have to wait.

To help reduce ER wait times, health care facilities encourage you to plan ahead for care, so when you’re sick or hurt, you know if the ER is right for your medical condition.

An emergency room visit can take up time and money if your problem is not life-threatening. Consider other care options, such as an urgent care center, convenience care clinic, your doctor, or a virtual doctor visit (video chat/telehealth)—all of which could be faster and save you money out of your own pocket if the medical problem is non-life threatening.

If you have health insurance, be sure to check your plan documents to see what types of care options are eligible for coverage under your plan, including whether or not you need to stay in your plan’s network.

Is taking an ambulance to the emergency room free?

An ambulance ride is not free, but your insurance may cover some of the costs for the ride, as well as the emergency room visit. Check your plan benefits to see what out-of-pocket expenses you are responsible for when it comes to an ambulance ride and a visit to the ER.

Plan ahead for times you may need immediate medical care. Review the details of your health plan so you know the costs for an ER visit should you ever need it. Know when it’s best to go to the emergency room and when going somewhere else, like an urgent care center, convenience care clinic, your doctor, or even a virtual doctor visit (video chat/telehealth), is the right option that may save you time and money.

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Does Medicare Cover Emergency Room Visits?

Learn what costs are associated with your er trip, stay, and services..

Typically, yes, Medicare covers emergency room visits in the case of injury, sudden illness, or an illness that suddenly gets much worse.

For each emergency room visit you will pay a copayment amount. There is also a copayment for each hospital service.

In addition, you will pay 20% of the Medicare-approved amount for your doctor’s services (while Medicare covers the other 80%). Keep in mind that the Part B deductible applies in this scenario.

Note, however, that if you are admitted to the same hospital within 3 days of your emergency room visit, you won’t have to pay the copay, as it will then be considered part of your inpatient stay.

Does Medicare Cover Emergency Room Visits Abroad?

Generally, no, only in rare circumstances does Medicare cover emergency services in foreign countries.

Does Medicare Coverage Include Urgent Care Visits?

Yes, Medicare covers urgent care visits. Your Medicare Part B coverage will cover urgently needed care to treat sudden illness or injury that is not a medical emergency.

For your urgent care visit, you will pay 20% of the Medicare-approved amount for your doctor or healthcare provider services. The Part B deductible applies in this case too.

Note: If you are in a hospital outpatient setting, you will also have to pay a copayment to the hospital.

What Does Medicare Part B Cover?

When you sign up for Medicare Part B, you receive coverage for both medically necessary services and preventive services.

This includes some of the more expensive services you might experience during a hospital stay, procedures like surgery, radiation, diagnostic imaging, chemotherapy, dialysis, among others.

Part B covers preventive medical services like ambulance rides, doctor visits, screenings, and diagnostic tests. It also covers a number of preventive care measures such as flu shots, colonoscopies, and mammograms.

Medically Necessary Services:

Medically necessary services and supplies are those used for diagnosis and treatment of medical conditions.

These services and supplies must meet the accepted standards of medical practice. This includes the use of medical equipment like wheelchairs, hospital beds, and oxygen equipment.

Preventive Services:

Preventive services are those that prevent illness or detect it early enough for optimal treatment.

This includes diagnostic tests like MRIs, EKGs, CT scans, and X-rays. It also applies to covered screenings such as pap tests, HIV screening, glaucoma tests, hearing tests, diabetes screening, and colorectal cancer screenings.

If your healthcare provider accepts assignment, you often don’t have to pay anything for these preventive services.

Up Next: What Does Medicare Cover?

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Emergency department visits exceed affordability threshold for many consumers with private insurance

By Hope Schwartz Twitter ,  Matthew Rae Twitter ,  Gary Claxton ,  Dustin Cotliar,  Krutika Amin , and  Cynthia Cox Twitter

December 16, 2022

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Introduction

The high cost of emergency care may impact patients’ ability to afford treatment , with almost half of US adults reporting they have delayed care due to costs. Almost 1 in 10 Americans have medical debt , and about half of American households do not have the liquid assets to afford an average employer sponsored plan deductible. More than one third of US adults are unable to afford a $400 medical expense without borrowing.

Costs of medical emergencies present an additional financial burden on top of already costly health insurance premiums ranging $1,327 for single coverage and $6,106 for family coverage, on average, for workers with employer sponsored insurance. Variation in emergency department billing may make it difficult to predict the cost of an emergency department visit and subsequent financial liability. Recently, the No Surprises Act legislation aimed to curb unexpected emergency medical costs by prohibiting out-of-network billing for emergency services.

In this analysis, we use 2019 insurance claims data from the Merative MarketScan Commercial Database, which captures privately insured individuals with large employer health plans. We look at the total and out-of-pocket costs of emergency department visits for this group, overall and by diagnosis and severity level. We also look at which services contribute most to the costs of emergency department visits and examine regional variation in emergency department costs. Finally, we look at the demographic profile of consumers who visited the emergency department and the relationship between emergency department spending and annual spending for enrollees.

We find that enrollees spend $646 out-of-pocket, on average, for an emergency department visit. Enrollees with high annual health spending were more likely to visit the emergency department; the majority of enrollees in the top 10% of annual health care spending had at least one emergency department visit during the year. The most expensive components of most emergency department visits include evaluation and management charges, imaging, and laboratory studies, and facility fees make up 80% of the cost of visits. Cost varies by disease, visit complexity, and geographic region.

Large employer plan enrollees’ emergency department visits cost $2,453, on average, with enrollees responsible for $646 in out-of-pocket costs

On average, enrollees in large employer health plans who have an emergency department visit spend $646 out-of-pocket on the visit. There is significant variation in emergency department spending, with 25% of visits costing over $907 out-of-pocket and another quarter costing less than $128 out-of-pocket. These out-of-pocket costs for a single emergency department visit may be more than some people with private insurance can afford and, in some cases, could entirely deplete a consumer’s savings. For example, about 1-in-5 people (21%) with private insurance living in single-person households have less than $1,000 in liquid assets.

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These amounts only include out-of-pocket spending required by the insurer. Before the No Surprises Act went into effect in January 2022, privately insured patients who visited the emergency department frequently had out-of-network claims on their visit, putting them at risk of providers sending them surprise balance bills. The No Surprises Act now prohibits most surprise out-of-network billing, but does not apply to ground ambulances . Any balance bill that a patient received from a provider would not appear in claims data and therefore would have been in addition to the out-of-pocket amounts shown here.

In total, enrollees and insurers paid $2,453, on average, per visit, with one quarter of visits costing $970 or less and another quarter costing $3,043 or more. All the costs described in this analysis are for the emergency department visits only, including professional services and facility fees, and do not include any spending on subsequent hospitalizations.

Facility fees contribute significantly more than professional fees to total visit cost

Emergency department bills are categorized as facility fees or professional fees. Professional fees are for services provided by clinicians, and facility fees include bills for services rendered using equipment owned by the facility, including laboratory or imaging studies. These fees are considered “overhead” for emergency departments and help facilities maintain appropriate staffing levels and technical resources. Evaluation and management charges also have a facility fee component for the equipment, staffing, and administrative resources used by the physician in their management. We find that facility fees make up 80% of total visit cost.

Evaluation and management charges make up the largest share of costs

Including both the professional fee and facility fee components of charges, the largest contributor to spending on a typical emergency department visit is the evaluation and management charge, which accounts for almost half (44%) of average visit costs. Evaluation and management charges are bills for the assessment of a patient that are not related to specific procedures or treatments provided; these services cost over $1,100 per visit, on average.

Imaging charges, including radiologist interpretation fees, make up an additional 19% of the average emergency department visit charge and cost $483, on average. The highest cost routinely performed imaging services include x-rays of the chest and CT scans of the head, chest, abdomen, and pelvis. Over half of visits (55%) include a charge for imaging services. About half of patients (49%) are charged for laboratory studies, including blood tests, which cost $230 on average. Other high cost but less common charges include surgical charges for patients with appendicitis and other conditions requiring surgery without inpatient admission, as well as ambulance charges for transport.

Heart attacks and appendicitis among the most expensive common conditions treated in the emergency department

Costs of emergency department visits depend on diagnosis. We selected nine common reasons to visit the emergency department that vary in complexity of management. More severe conditions, or those with more intervention required, are the most expensive. Of the nine specific diagnoses that we evaluated, the lower-cost diagnoses were those that generally do not require imaging or extensive treatment in the emergency department. These included upper respiratory tract infections ($1,535 total, $523 out-of-pocket), skin and soft tissue infections ($2,005 total, $572 out-of-pocket), and urinary tract infections ($2,726 total, $683 out-of-pocket). While these diagnoses can occasionally require admission to the hospital, in otherwise healthy adults they are typically evaluated with basic laboratory studies and discharged with prescriptions.

The most expensive emergency department diagnosis among those we examined is appendicitis, which, on average, costs $9,535 ($1,717 out-of-pocket) per visit. Appendicitis is almost two times as expensive as the next most expensive diagnosis we looked at, heart attack. 11% of enrollees with a diagnosis of appendicitis had surgical charges associated with their emergency department visit. Surgical costs may be included in emergency department outpatient billing because these patients are often discharged after surgery without being admitted to the hospital. In contrast, other emergency department visits requiring surgery are often admitted to the hospital and have surgical charges during their inpatient visit. Enrollees who had surgery had more expensive visits by over $2,000 compared to those who did not; however even without surgery, visits for appendicitis were almost four times as expensive as the average emergency department visit (and more than twice as expensive out-of-pocket).

Enrollees with emergency department visits have variable annual spending depending on diagnosis

In addition to the costs of the emergency department visit itself, enrollees who visit the emergency department at least once during the year have higher annual health care spending. Annual spending includes the cost of all claims for each patient in 2019, either before or after their emergency department visit. Though appendicitis was the most expensive emergency department visit among the diagnoses we analyzed, enrollees with appendicitis in 2019 incurred an average of $24,333 in additional health care spending, which was comparable to lower cost diagnoses. Enrollees with heart attacks had at least two times more annual spending than any other diagnosis ($52,993), while enrollees with upper respiratory tract infections had the lowest annual spending ($13,727).

These differences in annual costs may reflect spending both directly related and unrelated to the emergency department visit. For example, enrollees with heart attack emergency department visits may have high annual spending because of follow-up, medications, or hospitalizations after their heart attacks. However, their high annual spending may also reflect more comorbidities and higher healthcare utilization at baseline. In contrast, appendicitis, the most expensive emergency department visit, is correlated with relatively lower annual costs; unlike heart attacks, appendicitis often occurs in younger, healthier people and requires comparatively little additional post-surgical follow-up or treatment.

The most complex emergency visits are more than 6 times as expensive as the least expensive visits, but insurers pay an increasing share of the visit as complexity increases

Emergency department visits are coded by complexity during the billing process, from 1 (least complex) to 5 (most complex). Each evaluation and management charge is associated with a procedure code ranging from level 1 to level 5 (99281 to 99285), which are generated by hospital coding professionals based on the physicians’ medical note. Criteria are defined by the Centers for Medicare and Medicaid Services ( CMS ) and based on the complexity of documentation and medical decision making. Patients with level 1 complexity codes require straightforward medical decision making, with self-limited or minor presenting problems, such as rashes or medication refills. Patients with level 5 codes require high complexity medical decision making and present with life- or limb-threatening conditions, such as severe infections or cardiac arrests.

The lowest complexity visits cost $592 on average, with enrollees responsible for $205, or about one-third of the total visit cost. As visits increase in complexity, both out-of-pocket costs and costs covered by insurance increase. For the highest complexity visits, the health plan covers $3,015 on average, or eight times the cost of the lowest complexity visits. On average, patients pay $840 out-of-pocket for the highest complexity visits, which is four times their out-of-pocket costs for the lowest complexity visits.

Higher complexity visits are more expensive for multiple reasons. In general, evaluation and management charges are higher cost for more complex patients. Also, patients with more complex medical conditions generally receive more diagnostic tests, medication, and other treatment, which increases the cost of the visit. For the lowest complexity visits, evaluation and management charges account for almost half (47%) of the overall visit cost. In contrast, evaluation and management charges for the highest complexity visits account for about one-fourth (27%) of the total visit cost, with additional services including tests and treatment making up a larger share of the cost.

Emergency department costs vary by geographic region

We analyzed the top 20 metropolitan statistical areas (MSAs) by population, where data are available. Overall, the San Diego, CA area had the most expensive average ED visits ($3,761 on average). San Diego ED visits were more than twice as expensive as Baltimore, MD, the least expensive MSA in our analysis ($1,645 on average). Expensive MSAs were geographically distributed in all regions of the country including the South, West, Northeast, and Midwest. Within each MSA, there was significant variation in visit costa. For example, 25% of visits in Oakland, CA cost less than $1,236 on average, while 25% cost more than $4,436 on average.

Some variation may be based on the distribution of diagnoses in each area, with more serious or complex diagnoses leading to higher cost visits. For example, if a metro area sees higher than average volume of appendicitis, heart attacks, or other high-cost diagnoses, that would drive up regional emergency department costs.

For common diagnoses, Texas and Florida MSAs are among the most expensive

If we examine costs for specific diagnoses, we can minimize some of this variation in reasons for visits and gain a better understanding of how prices and service intensity affect the rankings. We selected two common, moderate-cost reasons for emergency department visits: low back pain and lower respiratory infections. While these visits can range in complexity and treatment required, they usually do not require hospital admission or high-cost treatment. Low back pain includes patients who present with the symptom of low back pain, regardless of diagnosis. Lower respiratory tract infection includes infectious causes of pneumonia and bronchitis. This analysis was limited to MSAs in which there were >500 cases of each diagnosis in 2019.

Visit costs for both diagnoses in Dallas, TX, Houston, TX, Fort Worth, TX, and Orlando, FL are in the top five most expensive MSAs with >500 cases. For low back pain visits, the Orlando, FL, Fort Worth, TX, Dallas, TX, and Houston, TX areas are each more than twice as expensive as the Warren, MI and Detroit, MI areas, on average. This trend is similar for lower respiratory tract infections. Within MSAs, variation in costs exist for both diagnoses. For example, for low back pain visits, there is more than a $3,000 difference between the least expensive and most expensive quarter of visits in Fort Worth, TX, Dallas, TX, and Houston, TX.

12% of large employer group enrollees went to the emergency department in 2019

We find that 12% of large group enrollees under age 65 had at least one emergency department visit in 2019, and of enrollees with emergency department visits, 80% had only one visit. 20% had more than one visit, and 7% had more than two visits. Emergency department visits were associated with higher annual health care spending, with almost half of enrollees in the top 25% of annual spending having at least one emergency department visit during the year.

We find that the average emergency department visit exceeds the threshold that some consumers can pay without borrowing, and even one emergency department visit in a year may create financial hardship for enrollees in large employer plans. For example, one quarter of emergency department visits for large employer enrollees cost over $907 out-of-pocket. Meanwhile, about 1-in-5 people with private insurance do not have $1,000 in liquid assets, and almost half of US adults report that they would not be able to pay a $500 medical bill without going into debt. Emergency department visits range significantly in cost depending on diagnosis, visit complexity, and geographic area. These variations may present challenges for consumers trying to predict the cost of their emergency department visit prior to going to the emergency department.

Several factors contribute to the variability of emergency department charges. First, unlike other forms of outpatient care including primary care or urgent care visits, emergency departments charge facility fees to offset the cost of keeping emergency departments open and staffed 24/7. These fees vary widely and are increasing at a faster rate than overall health care spending. The facility component represented 80% of total emergency department spending in our analysis. Many hospitals and health care providers consider these costs necessary given their mandate to provide emergency triage and treatment to allcomers. A second contributor to variation is that services are often billed at different complexity levels, and visits that are billed as more complex are more expensive . In some cases, even similar services are billed at different prices by different facilities. Notably, surprise out-of-network medical bills from emergency departments have contributed to high emergency costs for consumers, though the cost of any balance bills would be outside the scope of our claims data. The implementation of the No Surprises Act in January 2022 will generally curb surprise medical billing for emergency care.

As seen in non-emergency spending , we find that emergency department costs vary by geographic area. Among the most expensive MSAs in our analysis were MSAs located in Texas, Florida, California, Colorado, and New York. Interestingly, the most expensive regions for ED care do not align with the most expensive regions for overall health care spending. These comparisons suggest that our findings are not solely related to overall high health care prices in these areas and may reflect other factors including the age and medical complexity of the population or differences in local norms and practice patterns. State-level emergency department regulation may also play a role—states with higher numbers of freestanding , non-hospital affiliated emergency departments (which are associated with higher spending on emergency care) were among the most costly in our analysis.

The financial implications of visiting the emergency department vary widely. Not all the variation in total charges is reflected in out-of-pocket costs, since differences in cost by complexity level are smaller after insurance covers its portion of the bill. However, the most complex emergency department visits have four times higher out-of-pocket costs than the least complex visits. Even the least complex visits, some of which could be treated by a primary care office or urgent care center, cost an average of $205 out-of-pocket ($592 total). Given facility fees and relatively high evaluation and management charges in emergency departments, insurers and patients are paying more when receiving care for these conditions at emergency departments than they would using primary or urgent care. These lower complexity visits may represent a substantial avoidable cost to patients and the health care system at large.   

High health care costs are of foremost concern for US adults, leading people to skip recommended medical treatment or delay necessary care. Even in the era of new price transparency regulation , which aims to improve consumer access to prices for elective care, emergency department consumers often do not know what testing or treatment they will need, so it is difficult to assess the costs of a visit upfront. Further, in an emergency situation, patients may not be able to choose their provider or facility if they are brought in by ambulance or otherwise unable to direct their care. Lastly, lack of availability and standardization in data may make it difficult for patients to use price transparency data in real time to make decisions about accepting tests and treatment in an emergency. The high and variable cost of emergency department visits represents an opportunity for future policy changes to protect consumers from unaffordable medical bills.

This analysis is based on data from the Merative MarketScan Commercial Database, which contains claims information provided by a sample of large employer plans. Enrollees in MarketScan claims data were included if they were enrolled for 12 months. This analysis used claims for almost 14 million people representing about 17% of the 85 million people in large group market plans (employers with a thousand or more workers) from 2004-2019. To make MarketScan data representative of large group plans, weights were applied to match counts in the Current Population Survey for enrollees at firms of a thousand or more workers by sex, age, state, and whether the enrollee was a policy holder or dependent.

Emergency department visits were flagged if an enrollee had an emergency department evaluation and management claim in the emergency department or the hospital on a given day. If an enrollee had either an emergency evaluation and management claim or another claim originating in the emergency department on the day prior to or after the flagged day, we added the previous and or following day’s outpatient spending to the visit cost. This was to capture all emergency department services for visits that may have spanned overnight or multiple days. Over half (53%) of the spending in this analysis occurred in the emergency department, with another 42% occurring in the hospital, which may occur when a patient receives a test or procedure in a location outside the emergency department during their visit.

Claims were included if they were above $100 and below the 99.5 th percentile of cost. Selected conditions were generated from a literature review of common emergency department diagnoses and defined using ICD10 codes. Enrollees were considered to have a certain diagnosis if the relevant ICD10 code appeared in the “Diagnosis 1” column in one or more claims on an emergency department visit day. While emergency department claims have up to four diagnoses, diagnoses listed in 2-4 were not used to identify relevant conditions because these diagnoses were most often incidentally found rather than related to the reason for presenting to the emergency department. For specific diagnosis definitions: Heart attack includes acute STEMI and NSTEMI, and excludes complications from prior heart attacks or angina; UTI includes acute cystitis, UTI and pyelonephritis; Kidney stone includes renal calculus in any location and renal colic; Lower respiratory infection includes pneumonia and bronchitis. Surgical charges for acute appendicitis include both open and laparoscopic surgical charges. Annual spending was defined as the total spending for each enrollee in the year 2019, which could occur before and/or after their emergency department visit depending on the time of year of the emergency department visit.

This analysis has some limitations. First, there is a chance that we could incorrectly include non-emergency outpatient care (such as a next-day, follow up primary care appointment) in our estimate of emergency department visit costs. Secondly, when accounting for annual spending, we do not control for health status prior to the emergency department visit. Therefore, the increase in annual health spending for patients who visit the emergency department for certain conditions may be because these patients are sicker and higher healthcare utilizers at baseline, rather than specific follow-up costs incurred for the emergency department visit itself. For selecting relevant diagnoses, we only include claims in which a particular diagnosis occurs as the primary diagnosis. Third, the MarketScan database includes only charges incurred under the enrollees’ plan and do not include balance billing to enrollees which may have occurred. Lastly, our findings only represent enrollees in large group employer sponsored plans and may not be generalizable to other groups.

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In-home emergency care cuts costs, but needs more payer buy-in

At-home emergency care is gaining momentum — and could cost millions less — but reimbursement challenges create an access barrier for some patients.

Deploying healthcare in patients' homes gained traction during the COVID-19 pandemic as a way to ease overcrowding at hospitals and prevent the virus from spreading. Emergency department care at home lets patients bypass the waiting room through referrals from hospitals or primary care providers if they determine patients do not have life-threatening illnesses or injuries. While many private insurers reimburse for such care, traditional fee-for-service Medicare and Medicaid do not pay for it as a stand-alone service.

Related: Hospital mergers could strain labor market, employer health plans

Emergency department-at-home programs deploy paramedics or nurses to check vital signs, draw blood and take x-rays with portable imaging devices. Physicians supervise the visits via telehealth, then refer patients to primary care providers for further treatment or to hospital emergency departments if more complex care is needed.

Healthcare technology company Medically Home and primary care provider Atrius Health , a division of UnitedHealth Group's Optum Health, offer emergency department-care-at-home through a partnership in the Boston area. A study they published last week in the New England Journal of Medicine found more than 83% of 3,668 patients who received emergency care at home over two years   did not require a trip to the hospital, saving Atrius approximately $4.5 million.

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Medically Home launched its service in 2020 and has served approximately 7,000 patients through contracts with three provider groups, including Atrius. The primary care provider has value-based care contracts with most of its patients and takes on the full risk for their care.

Hospital emergency departments are the default care option for many Americans and are expected to account for about 150 million visits this year, according to the Emergency Department Benchmarking Alliance, a nonprofit that represents more than 2,000 emergency departments. They are also the most expensive places to get healthcare. The average emergency department visit costs about $2,700 versus $185 at an urgent care facility, according to UnitedHealth Group’s website.

Companies including Medically Home and Denver-based DispatchHealth  see emergency department-at-home as a huge opportunity to save millions of dollars in unnecessary hospital visits.

“Health systems sometimes get overrun and they want to make sure that patients get the right type of care," said Dr. Phil Mitchell, DispatchHealth's chief medical officer. “In some circumstances, they are actually actively looking to decant what comes into their emergency department.”

DispatchHealth launched its emergency department-at-home program in 2015 and has partnerships with 150 health plans, value-based care providers and health systems. The company has provided care to 1.2 million patients in 50 locations across 23 states, according to Mitchell. It wants to bring the service to another seven locations by the end of this year.

Falls Church, Virginia-based Inova Health Systems contracted with DispatchHealth two years ago to treat some patients in their homes. The service helps the hospital free up beds for sicker patients and helps emergency medical assistance teams turnaround ambulances more quickly, said Toni Arabell, Inova Health System’s chief clinical officer of enterprise operations.

New providers are also jumping into at-home emergency care, including Minnesota-based  Lifespark , which operates senior living facilities and provides primary care and home health services to about 20,000 older adults in the Minneapolis area. On Tuesday, the company launched an urgent response service that will provide in-home emergency department care to patients enrolled in certain Medicare Advantage plans who live in its communities or receive primary care services from Lifespark.

CEO Joel Theisen said urgent response aims to close care gaps for about 3,000 chronically ill older adults who frequently use hospital emergency departments and can cost Lifespark thousands of dollars per visit.

“The igniter for setting off the bomb of costs is the acute hospital event,” Theisen said. “If you can keep them out of the emergency room, everyone wins big.”

Still, a large cohort of patients covered by traditional fee-for-service Medicare and Medicaid don’t have access to home-based emergency department care because those government programs don't fully cover for the service.

A spokesperson for DispatchHealth said the company is reimbursed for urgent medical services by Medicare and Medicaid, but the programs may not fully cover the cost of care. The company is optimistic traditional Medicare and Medicaid will eventually pay for the entire service, the spokesperson said.

Medically Home plans to continue expanding the emergency department-care-at-home program despite reimbursement gaps, according to Dr. Greg Snyder, the company’s vice president of clinical strategy and quality improvement. But he said getting buy-in from all payers would be helpful.

“We need to be delivering the service innovations that are going to support the home-based care ecosystem and [emergency department]-at-home is one of those things,” Snyder said.

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ER or urgent care? Condition, cost could decide where you should go in Springfield

With everyone being more active during the summer, there are more opportunities for injury. It can be difficult to tell whether to take someone to urgent care or to the emergency department. So how do you know whether to wait for an appointment with your primary care provider, visit urgent care or go to the emergency room?

Here are some things to consider when trying to decide, including what symptoms you're dealing with and the cost associated with visits.

If you are in immediate danger, call 911 immediately.

What conditions necessitate going to the emergency room?

Unless a condition is life-threatening, it's generally better to go to urgent care rather than the emergency room. The University of Chicago says that emergency rooms are for when a person is "systemically sick": when an illness affects the whole body, there's sudden onset of severe symptoms or severe pain, a fever that won't break or the inability to move an arm or leg or breathe normally.

According to Mercy , the following conditions should be seen at the emergency room:

• Severe breathing difficulty;
• Chest pain;
• Heart rate over 120 to 150 beats per minute;
• Someone fainting or becoming unresponsive;
• Difficulty speaking;
• Heavy bleeding;
• Broken bones visible through the skin;
• Severe burns;
• Allergic reaction with breathing difficulty;
• Extremely hot or cold;
• Poisoning or drug overdose;
• New severe headache;
• Sudden intense, severe pain;
• Sudden blindness or vision change.

When should you go to urgent care?

According to Mercy and CoxHealth, the following conditions can be treated at urgent care:

• Cough, cold and flu;
• Sore throat;
• Ear problems;
• Sprains or possible broken bones;
• Minor burns, scrapes or cuts;
• Animal or insect bites;
• Urinary discomfort;
• Flu, strep or mono.

Some urgent care locations will also do sports physicals, DOT physicals and occupational medicine services like drug testing and return-to-work exams.

Time, cost can also factor into decision

If the condition is something that isn't pressing, sometimes an appointment with a primary care provider can be your best bet when it comes to saving time and money, according to health insurance company Blue Cross Blue Shield . Your PCP already has your medical history and the co-pay for a doctor's office visit is much less than an emergency room visit co-pay.

Before heading to an urgent care clinic, check to see if your insurance covers services that location. Urgent care costs depend on the service provided as well as the type of health insurance you have — UnitedHealthcare says an urgent care visit costs an average of $185 for their members, while an emergency room visit can cost an average of $2,700.

Emergency departments handle cases based on severity, so seeking care for a non-life-threatening condition can mean a longer wait. According to data released by the Center for Medicare and Medicaid Services , from July 2022 to June 2023, patients spent an average of 157 minutes in Missouri emergency department before leaving from the visit.

Urgent care wait times are not tracked by the CMS, but UnitedHealthcare and urgent care clinics estimate the average wait at 30 minutes or less. Unlike emergency departments, urgent care patients are generally seen on a first-come, first-served basis.

More: June 20 is the first day to buy fireworks from Missouri retailers. Here's how to stay safe

What are my options in Springfield?

Both major health systems in the Springfield area — Mercy and CoxHealth — offer emergency department and urgent care services.

CoxHealth has two emergency department locations in Springfield and Mercy has one.

• Cox North Emergency Department, 1423 N. Jefferson Ave., is open 24/7. Phone is 417-269-4083.
• Cox South Emergency Department, 3801 S. National Ave., is open 24/7. Phone is 417-269-3393.
• Mercy Hospital Springfield Emergency Department, 1235 E. Cherokee St., is open 24/7. Phone is 417-820-2000.

Both health systems have four urgent care locations in Springfield. With the exception of CoxHealth's Turner Center, all CoxHealth urgent care locations are open 8:30 a.m. to 8 p.m. daily. Additionally, CoxHealth's urgent care location at 1429 W. Sunshine St. is temporarily closed. Mercy's urgent care centers are open 8 a.m. to 8 p.m. Monday through Friday and 9 a.m. to 5 p.m. Saturday and Sunday.

• Mercy GoHealth Urgent Care: 303 W. Sunshine St. Phone is 417-986-0452.
• Mercy GoHealth Urgent Care: 900 E. Battlefield Rd., Suite 124. Phone is 417-986-1289.
• Mercy GoHealth Urgent Care: 3233 E. Sunshine St. Phone is 417-812-8149.
• Mercy GoHealth Urgent Care: 2150 W. Republic Road. Phone is 417-986-1291.
• CoxHealth Urgent Care: 1819 S. National Ave. Phone is 417-269-2700.
• CoxHealth Urgent Care: 3525 E. Battlefield Road. Phone is 417-269-0065.
• 24/7 Urgent Care Plus Springfield at the Turner Center, 1000 E. Primrose St. Phone is 417-269-9812.

Since the 24/7 Urgent Care Plus at 1000 E. Primrose St. is hospital-based, it may have higher costs, according to CoxHealth.

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2024-06-27-MLNC

Thursday, June 27, 20 24

CY 2025 Home Health Prospective Payment System Proposed Rule

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Learn about the CY 2025 Home Health Prospective Payment System proposed rule. 

More Information:

• Rule and related files  
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CMS released  technical FAQs for pharmacies (PDF) about the Preexposure Prophylaxis (PrEP) Using Antiretroviral Drugs to Prevent HIV National Coverage Determination (NCD), which we expect to release in late September 2024. We got public feedback asking us to release more technical information on how to submit future Medicare Part B claims in advance of the final NCD. 

We expect the final NCD will be similar to the proposed NCD that was published on July 12, 2023, and pharmacies should prepare now for this transition. We’re sharing as much information as possible before issuing the final NCD to avoid disruptions for people with Medicare.

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MACs will adjust claims you bring to their attention.

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Register for this conference by July 31, 2024.

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• Provide a unique learning and networking opportunity

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• New information for HCPCS codes K1007 and E2298 effective April 1, 2024

Your Medicare Administrative Contractor will adjust claims for code E2298 with dates of service on or after April 1, 2024, that you bring to their attention.

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CMS posted recordings from updated Medicare Ground Ambulance Data Collection System Instrument webinars:

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The CDC issued a Health Alert Network Health Advisory  to notify health care providers, public health authorities and the public of an increased risk of dengue virus (DENV) infections in the U.S. in 2024. Global incidence of dengue in 2024 has been the highest on record for this calendar year; many countries are reporting higher-than-usual  dengue case numbers . In 2024,  countries in the Americas  have reported a record-breaking number of dengue cases, exceeding the highest number ever recorded in a single year. From January 1 – June 24, 2024, countries in the Americas reported more than 9.7 million dengue cases, twice as many as in all of 2023 (4.6 million cases). In the U.S., Puerto Rico has declared a public health emergency (1,498 cases) and a higher-than-expected number of dengue cases have been identified among U.S. travelers (745 cases) from January 1 – June 24, 2024. In the setting of increased global and domestic incidence of dengue, health care providers should take steps including:

• Have increased suspicion of dengue among people with fever who have been in areas with frequent or continuous dengue transmission within 14 days before illness onset
• Order appropriate diagnostic tests for acute DENV infection: reverse transcription polymerase chain reaction [RT-PCR] and IgM antibody tests, or non-structural protein 1 [NS1] antigen tests and IgM antibody tests
• Ensure timely reporting of dengue cases to public health authorities
• Promote mosquito bite prevention measures among people living in or visiting areas with frequent or continuous dengue transmission

See the full  Health Advisory for more information.

The Administration for Strategic Preparedness and Response's  Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) released new and updated health care preparedness resources, which could help you comply with some of the CMS emergency preparedness requirements:

• Health Care Facility Extreme Weather Resilience and Mitigation recording: discusses how to incorporate lessons learned from past disasters in the design or retrofitting of climate-resilient facilities
• On-Campus Health Care Facility Armed Assailant Planning Considerations checklist: helps planners prepare their facilities to mitigate, respond to, and recover from an active shooter or armed assailant situation on campus
• Medical Operations Coordination Centers Toolkit (Version 3.0): suggests how to optimally-balance patients across health care facilities and systems
• LGBTQI+ Community Members and Disaster Preparedness and Response  Topic Collection: highlights key considerations for LGBTQI+ populations and the health care providers and preparedness planners who serve them during and after a disaster
• CMS Emergency Preparedness Rule webpage
• ASPR TRACIE Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers (CMS Rule) webpage

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View the  Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

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Bill Of The Month

It’s called an urgent care emergency center — but which is it.

Renuka Rayasam

Emily Siner

In severe pain and uncertain of its cause, Tieqiao Zhang of Dallas says he didn’t want to wait for an appointment with his regular doctor, but he also wasn’t sure if he needed emergency care. He visited a clinic on the campus of Dallas’ largest public hospital — and was charged 10 times what he expected. Laura Buckman/KFF Health News hide caption

One evening last December, Tieqiao Zhang felt severe stomach pain.

After it subsided later that night, he thought it might be food poisoning. When the pain returned the next morning, Zhang realized the source of his pain might not be as “simple as bad food.”

He didn’t want to wait for an appointment with his regular doctor, but he also wasn’t sure if the pain warranted emergency care, he said.

Zhang, 50, opted to visit Parkland Health’s Urgent Care Emergency Center, a clinic near his home in Dallas where he’d been treated in the past. It’s on the campus of Parkland, the city’s largest public hospital, which has a separate emergency room.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it !

He believed the clinic was an urgent care center, he said.

A CAT scan revealed that Zhang had a kidney stone. A physician told him it would pass naturally within a few days, and Zhang was sent home with a prescription for painkillers, he said.

Five days later, Zhang’s stomach pain worsened. Worried and unable to get an immediate appointment with a urologist, Zhang once again visited the Urgent Care Emergency Center and again was advised to wait and see, he said.

Two weeks later, Zhang passed the kidney stone.

Then the bills came.

The patient: Tieqiao Zhang, 50, who is insured by BlueCross and BlueShield of Texas through his employer.

Medical services: Two diagnostic visits, including lab tests and CAT scans.

Service provider: Parkland Health & Hospital System. The hospital is part of the Dallas County Hospital District.

Total bills: The in-network hospital charged $19,543 for the two visits. BlueCross and BlueShield of Texas paid $13,070.96. Zhang owed $1,000 to Parkland — a $500 emergency room copay for each of his two visits.

What gives: Parkland’s Urgent Care Emergency Center is what’s called a freestanding emergency department .

The number of freestanding emergency rooms in the United States grew tenfold from 2001 to 2016 , drawing attention for sending patients eye-popping bills. Most states allow them to operate, either by regulation or lack thereof . Some states, including Texas, have taken steps to regulate the centers, such as requiring posted notices identifying the facility as a freestanding emergency department.

Urgent care centers are a more familiar option for many patients. Research shows that, on average, urgent care visits can be about 10 times cheaper than a low-acuity — or less severe — visit to an ER.

But the difference between an urgent care clinic and a freestanding emergency room can be tough to discern.

Generally, to bill as an emergency department, facilities must meet specific requirements, such as maintaining certain staff, not refusing patients and remaining open around the clock.

The freestanding emergency department at Parkland is 40 yards away from its main emergency room and operates under the same license, according to Michael Malaise, the spokesperson for Parkland Health. It is closed nights and Sundays.

(Parkland’s president and chief executive officer, Frederick Cerise, is a member of KFF’s board of trustees. KFF Health News is an editorially independent program of KFF.)

The hospital is “very transparent” about the center’s status as an emergency room, Malaise told KFF Health News in a statement.

Malaise provided photographs of posted notices stating, “This facility is a freestanding emergency medical care facility,” and warning that patients would be charged emergency room fees and could also be charged a facility fee. He said the notices were posted in the exam rooms, lobby and halls at the time of Zhang’s visits.

Zhang’s health plan required a $500 emergency room copay for each of the two visits for his kidney stone.

When Zhang visited the center in 2021 for a different health issue, he was charged only $30, his plan’s copay for urgent care, he said. (A review of his insurance documents showed Parkland also used emergency department billing codes then. BCBS of Texas did not respond to questions about that visit.)

One reason, “I went to the urgent care instead of emergency room, although they are just next door, is the copayment,” he said.

The list of services that Parkland’s freestanding emergency room offers resembles that of urgent care centers — including, for some centers, diagnosing a kidney stone, said Ateev Mehrotra, a health care policy professor at Harvard Medical School.

Having choices leaves patients on their own to decipher not only the severity of their ailment, but also what type of facility they are visiting all while dealing with a health concern. Self-triage is “a very difficult thing,” Mehrotra said.

Zhang said he did not recall seeing posted notices identifying the center as a freestanding emergency department during his visits, nor did the front desk staff mention a $500 copay. Plus, he knew Parkland also had an emergency room, and that was not the building he visited, he said.

The name is “misleading,” Zhang said. “It’s like being tricked.”

Parkland opened the center in 2015 to reduce the number of patients in its main emergency room, which is the busiest in the country , Malaise said. He added that the Urgent Care Emergency Center, which is staffed with emergency room providers, is “an extension of our main emergency room and is clearly marked in multiple places as such.”

Malaise first told KFF Health News that the facility isn’t a freestanding ER, noting that it is located in a hospital building on the campus. Days later, he said the center is “held out to the public as a freestanding emergency medical care facility within the definition provided by Texas law.”

The Urgent Care Emergency Center name is intended to prevent first responders and others facing life-threatening emergencies from visiting the center rather than the main emergency room, Malaise said.

“If you have ideas for a better name, certainly you can send that along for us to consider,” he said.

Putting the term “urgent” in the clinic’s name while charging emergency room prices is “disingenuous,” said Benjamin Ukert, an assistant professor of health economics and policy at Texas A&M University.

When Ukert reviewed Zhang’s bills at the request of KFF Health News, he said his first reaction was, “Wow, I am glad that he only got charged $500; it could have been way worse” — for instance, if the facility had been out-of-network.

The resolution: Zhang said he paid $400 of the $1,000 he owes in total to avoid collections while he continues to dispute the amount.

Zhang said he first reached out to his insurer, thinking his bills were wrong, before he reached out to Parkland several times by phone and email. He said customer service representatives told him that, for billing purposes, Parkland doesn’t differentiate its Urgent Care Emergency Clinic from its emergency department.

BlueCross and BlueShield of Texas did not respond to KFF Health News when asked for comment.

Zhang said he also reached out to a county commissioner’s office in Dallas, which never responded, and to the Texas Department of Health, which said it doesn’t have jurisdiction over billing matters. He said staff for his state representative, Morgan Meyer, contacted the hospital on his behalf, but later told him the hospital would not change his bill.

As of mid-May, his balance stood at $600, or $300 for each visit.

The takeaway: Lawmakers in Texas and around the country have tried to increase price transparency at freestanding emergency rooms, including by requiring them to hand out disclosures about billing practices.

But experts said the burden still falls disproportionately on patients to navigate the growing menu of options for care.

It’s up to the patient to walk into the right building, said Mehrotra, the Harvard professor. It doesn’t help that most providers are opaque about their billing practices, he said.

Mehrotra said that some freestanding emergency departments in Texas use confusing names like “complete care,” which mask the facilities’ capabilities and billing structure.

Ukert said states could do more to untangle the confusion patients face at such centers, like banning the use of the term “urgent care” to describe facilities that bill like emergency departments.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.  

Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR's Will Stone edited the audio and digital story.

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What to know about Medicare and hospital at home programs

These days, when people with Medicare get to the hospital, they’re increasingly asked: Would you prefer using our hospital at home program?

That can be an enticing option if you need acute care for any of 60 conditions like COPD, pneumonia, congestive heart failure and urinary tract infections but not for things requiring a brick-and-mortar medical center like surgery or an MRI.

In 2019, people with Medicare had over 800,000 hospitalizations that could have qualified for hospital at home, according to the actuarial and consulting firm Milliman.

The disruptions of hospital stays

“There’s lots of evidence that, on average, patients are more comfortable in the home,” says Pamela Pelizzari, principal and senior healthcare consultant at Milliman. “If you’ve ever been in the hospital, it’s disruptive. It’s not restful. You’re getting disturbed constantly for lots of things. There’s an infection risk that it makes sense to try and avoid.”

With hospital at home, “we try to make sure that patients get to sleep at night at their usual sleeping hours, not wake them at weird times of day and organize the care so it allows for good rest,” says Dr. Pippa Shulman, chief medical officer at Medically Home. 

Data on the quality and usefulness of hospital at home is fairly sparse. But a few studies have shown that compared to brick-and-mortar hospital stays, the in-home service lowers mortality rates, fall risks and the onset of delirium while helping patients avoid infections some get in hospitals.

What patients and caregivers say about hospital at home

Studies have also found high satisfaction rates from hospital-at-home patients and their caregivers . For people with Medicare, the out-of-pocket cost for hospital at home is generally the same as for receiving similar care in a hospital.

Increasingly, says Rami Karjian, the founder and CEO of Medically Home, hospital at home is “becoming the default standard to provide care for eligible patients, as opposed to an exception.”

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, calls hospital at home “a very effective, efficient way to care for patients.”

How hospital at home works

Hospital at home typically lasts for four or five days and can be declined by patients who prefer hospital stays. It has three components: daily in-person visits from doctors, nurses and paramedics; daily virtual visits from physicians and nurses at the hospital at home’s “command center” and Bluetooth-enabled remote monitoring from tablets and phones given to patients plus the personal emergency response devices they wear.

Advances in technology have made hospital at home much easier to provide, says Michael Dowling, co-author of The Aging Revolution and president and CEO of Northwell Health .

“Our tech kit takes about 15 minutes to set up,” says Medically Home’s Shulman.

Medical care provided by hospital at home can include IV antibiotics and infusions, EKGs, blood pressure monitoring, x-rays, and respiratory or oxygen therapy.

Typically, to qualify for hospital at home, people with Medicare need to first go to the hospital for an interview. If they’re selected as candidates, they then decide whether to enroll or to stay in the hospital.

Medicare and hospital at home

Hospital at home has been offered in the United States, England, Australia and Israel for decades, but Medicare typically didn’t cover it until the pandemic.

In 2020, however, when people without the virus wanted to stay out of hospitals and hospitals needed space for those requiring treatment for it, the Centers for Medicare and Medicaid Services (CMS) began allowing reimbursement for Traditional Medicare and private insurers’ Medicare Advantage plans.

Subsequently, hospital at home took off. In 2021, 186 hospitals offered it. Currently, about 320 hospitals in 37 states do, from Johns Hopkins in Baltimore to Mount Sinai in New York City to Sanford Health in Sioux Falls, S.D. to Presbyterian Healthcare Services in New Mexico.  

In 2022, Medicare’s hospital-at-home waiver was extended by two years.

“There’s no greater patient-centered care than care delivered in an individual’s home setting where they’re often most comfortable with their own sleeping accommodations and clothing, in addition to having easy access to their loved ones and their pets, who are often important elements in the return to health,” says Heather O’Sullivan, president of Mass General Brigham Hospital’s Healthcare at Home and a geriatric nurse practitioner.

Hospital at home fans and critics

Today, hospital at home has its fans—and its critics.

Lisa Rother, an Oklahoma City nurse, recalls the experience of one older man who had hospital at home from Medically Home, where she’s senior director of strategic marketing operations.

“He had been in hospitals multiple times for an infection of his bones and was losing his fingers gradually,” she says. “He wouldn’t stay in the brick-and-mortar hospitals because he felt very uncomfortable there. So, we hospitalized him within his home, helping him complete his full medical treatment and antibiotics and keep his hand.”

Rother says after the patient’s third or fourth day in the program, “he loved our nurses, he loved our physicians and completely changed his attitude.”

After all, she asked, “What better outcome can you have than being able to keep your limb rather than having an amputation?”

The American Hospital Association and American Medical Association are huge proponents of hospital at home.

But a 2023 report from the Emergency Care Research Institute said there hasn’t been enough reliable data on hospital-at-home outcomes. “No systematic evidence exists that H@H services to the acutely ill yield better patient care or lower costs compared to the current hospital-based system,” it said.

The nurses who oppose hospital at home

National Nurses United, the nation’s largest union and professional association of registered nurses, strongly opposes hospital at home.

The group calls it “Home All Alone” and “a grave threat to patient care and safety” that can “deprive people of professional, 24/7 nursing care.”

“Devices being deployed in patients’ homes can malfunction and give erroneous readings,” says Michelle Mahon, assistant director of nursing practices at National Nurses United. “There are also user curves. Imagine you’re very sick, running a high fever, can barely see straight and now you’re supposed to enter your own vital signs into an app or tool that maybe you can’t even see properly?”

Hospital-at-home providers and proponents reject those fears.

“We assume the patient and caregiver have no ability or knowledge” regarding the hospital-at-home tech devices, says Shulman.

Some critics, like National Nurses United, also worry about what could happen to hospital-at-home patients with medical emergencies.

“In the hospital, we are able to respond to a patient’s change of condition and recognize it before it becomes a crisis,” says Mahon. “Often, those changes are detected by skilled nurses before the data shows there’s a problem, especially in elderly people. There might be subtle changes in the way they talk or in their cognition, glassy eyes or in the smell of their breath. We can respond within seconds.”

Doctors are most apt to select patients for the hospital at home programs who are unlikely to have a sudden emergency “that would warrant an immediate crush of health care personnel descending,” says Foster.

Hospital-at-home programs often keep in contact with their patients for a month after their experience ends.

“We are making sure that our care plan works and you transition back to your primary care physician or specialist,” says Mark Prather, cofounder and executive chairman of the Dispatch Health hospital-at-home operator.

The Medicare rules for hospital at home

Each hospital at home program has its own technology and care system. But they all must adhere to these CMS rules for people on Medicare:

• At least one daily clinician visit, which can be remote after the initial in-person history and physical exam in the hospital or emergency department
• At least two in-person daily visits; if both are by a paramedic or “mobile integrated health practitioner,” there must also be a daily remote visit from a registered nurse
• An on-demand remote audio connection with someone from the hospital-at-home team who can immediately connect to an RN or physician
• Emergency response to a patient’s home within 30 minutes if needed

Questions to ask before signing up

If you’re considering getting hospital at home or are given the option, Northwell Health’s Dowling recommends asking: What kind of home-care capabilities does the organization have? How much hospital-at-home has it done? Are the nurses trained for the types of things that may need to be done?

Medically Home’s Karjian adds: “I’d ask, ‘If this was your dad, what would you recommend for them?’”

O’Sullivan, of Mass General Brigham, suggests finding out who’d be coming into your home and their credentials.

The American Hospital Association’s Foster thinks you should also inquire about how often the team members will come, how you’ll know what to do if there’s an emergency and how often you might need help from someone living in your home.

Hospital at home generally isn’t a good idea if you live alone. That’s because there may be times when you’ll need in-person assistance and the hospital-at-home crew won’t be with you.

What will happen after 2024?

Medicare’s hospital-at-home reimbursement rules will come to an end for people with Traditional Medicare January 1, 2025 (not for those with Medicare Advantage plans) unless Congress and the Biden administration extend the waiver.

The problem if Medicare stops allowing hospital at home, says Foster, is that “many hospitals are very, very full and often short of staff, which could provide some challenges for inpatient care.”

National Nurses United wants the Medicare waiver to end in 2024. But proponents like the American Hospital Association, the American Medical Association, the American Academy of Home Care Medicine and the American Telemedicine Association want to see an extension for at least five years.

“Congress has been talking a lot about how long to extend [the waiver], which I think is a good sign,” says Rachel Jenkins, the American Hospital Association’s senior associate director of federal relations.

The future for hospitals and hospital at home

If CMS does continue allowing Medicare reimbursement for hospital at home after 2024, experts said, that won’t mean the end of in-person hospital stays—though hospitals gradually may wind up becoming primarily for patients needing surgery or ICUs.

“I don’t think we’re going to be taking out your gall bladder in your living room,” says Prather. “But in 10 years, we will be admitting all the classic medical admissions that are just better at home.”

“Hospitals are one cog in the wheel, not the central cog as they were years ago,” says Dowling. “The other cogs are home care, post-acute care, ambulatory care and physical therapy care. We’ve got to maximize all of those opportunities and be creative about it.”

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Why Supporting Caregivers Could Make A Difference in Dementia Care

June 27, 2024.

Photo by Kevin Corcoran

Patients and their caregivers are often left to navigate the confusing world of dementia by themselves, but Medicare is launching a new program to change that.

Listen to the full episode below, read the transcript and scroll down for more information.

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At 80, Rose Carfagno of West Norriton, Penn., was charming, social and independent, still working as a hair stylist and going ballroom dancing every weekend. 

“She would work three days a week, and then she would dance Friday night, Saturday and Sunday,” said her daughter Rosanne Corcoran.

But over the next few years, Carfagno started showing signs of dementia. She struggled to remember to eat dinner, pay her bills and take her blood pressure medicine. She stopped working, stopped dancing. When the older woman fainted in 2015, Rosanne decided her mom needed to move in with her and her husband and their two kids, a few towns away.

“To scoop her up and bring her back to my house and say, ’Mom, you can’t go home again’ is heartbreaking because I’m taking something away from her,” Corcoran said.  “I’m not — the disease is, but it sure does feel like I am.”

As Carfagno’s mental and physical losses continued, the burden on Corcoran grew. She bathed and dressed her mom as well as the kids each day, took her to myriad doctors’ appointments, talked her through delusions in the middle of the night. Every day, fresh chaos.

“It’s the complete and utter, overwhelming feeling of never being on top of it,” said Corcoran. “Of never knowing enough and not thinking that you know enough.”

Rosanne Corcoran is just one of many family members and friends who do the vast majority of hands-on care for the nearly 7 million Americans living with Alzheimer’s disease and other dementias. According to the Alzheimer’s Association, all that unpaid work adds up to 18 billion hours a year, often saddling caregivers with their own financial stress, depression and other health issues .  

“I can tell you,” Corcoran said, “every caregiver is drowning for more help.”  

In hopes of easing that burden, Medicare, the federal government’s health insurance program for people 65 and over, is launching an eight-year pilot project this summer with a groundbreaking plan. The government will pay for programs that directly support the caregivers of people living with dementia. Medicare is betting that investing in caregivers will pay off by helping keep patients with dementia healthier and happier, without exhausting their families emotionally and financially. 

Help in the Trenches

Medicare’s program, called Guiding an Improved Dementia Experience – or GUIDE – is modeled on a handful of promising, smaller programs linked to academic institutions, including UCLA, UC-San Francisco (UCSF), Emory and Indiana University.

In Medicare’s version, each family will get a care coordinator — a sort of coach trained in dementia care, who knows the patient and the caregiver and can offer guidance and troubleshoot problems before they escalate. The coach or other member of the care team will be on call, 24/7. They will also help coordinate doctors visits and identify some adult day care or in-home care for the patient for up to a few hours a week, to lighten the caregiver’s load. 

“We’ve never tried anything like this before,” said Liz Fowler, Director of the Center for Medicare and Medicaid Innovation.

“The magic comes from the care coordinator who works with the patient outside the office … in the home, in the community, with the caregiver,” said Dr. Malaz Boustani, founding director of the Sandra Eskenazi Center for Brain Care Innovation , and one of the pioneers of this approach to dementia care.

As Boustani explains it, even as the patient continues to decline mentally, the care coordinator helps them and their families manage other symptoms that come along with dementia, such as agitation, depression, sleep disturbances. 

Boustani has seen firsthand how helpful this type of support can be.

A randomized controlled tria l of the program at Eskenazi Health, the hospital in Indianapolis where his program is based, found patients had fewer symptoms of dementia, and caregivers reported lower stress. Studies of similar programs at UCSF and UCLA found that patients had fewer emergency room visits and were able to continue living at home longer.

Avoiding expensive preventable hospitalizations and keeping patients happily at home and out of nursing homes longer, are two goals of the Medicare project. Right now people who have dementia cost Medicare almost three times as much as other patients. 

New Strategies to Ease Stress

Cindi Hart, a caregiver in Indianapolis, attributes her ability to keep her mom out of a nursing home to the dementia program based at Eskenazi Health. That’s where Hart met her mom’s care coordinator, Lauren Sullivan. 

“She was teaching me how to swim, how to tread water, how not to to gulp in the water of my mother’s illness,” Hart says of Sullivan.

Hart’s mom, Sidney Pfaff, 80, a retired nurse, was reluctant to give up control of her daily medications. But after Hart saw pills scattered all over the floor of her mom’s apartment one day, she tried to appeal to her mom’s sense of reason.

“She is walking through her apartment with the pills falling out of her hands,” Hart recalls. “And she’s like, ‘Oh, no, I take them, I take them I know what I’m doing.’ She was uncharacteristically belligerent and irate, to the point where she was screaming and her eyes were bulging,” Hart said.

The arguing went nowhere. On the way home, Hart called Sullivan, their care coordinator, who advised Hart to stop trying to reason with her mom. Pfaff was losing her ability to problem-solve and organize herself, Sullivan explained, though she’d always prided herself in exactly those qualities.

Hart now cites that conversation as a breakthrough moment.  

“In my heart I thought that my mother still had the ability to be logical,” Hart said, “It was a huge step – the program helped me understand that her logic has gone.”

With Sullivan’s help, Hart created a set of alarms and automatic pill dispensers to keep her mom on her medication regimen, while still letting her take the pills on her own. 

It worked for years.

Recently, with the dementia advancing, her mom moved from her own apartment to a nearby assisted living facility, where a nurse now comes by to help Pfaff take her meds. When Hart visits her mom several times a week, they no longer argue. They go on walks.  

Lauren Sullivan continues to check in regularly and field Hart’s questions as new challenges arise.

“Many of our patients don’t actually pass away from dementia,” Sullivan said. “The majority of them can plateau and stay pretty healthy for a long time.”

Eligibility for Medicare’s Caregiver Program is Limited – For Now

Medicare has yet to reveal exactly which health systems will be included in its pilot project, or how many families will be eligible; the agency promises more details in early July. In the meantime, Medicare has spelled out some eligibility criteria for patients:

• The patient must have a dementia diagnosis.
• They must have traditional Medicare insurance – that’s only about half of people over 65. Seniors on a Medicare Advantage plan aren’t eligible.
• The patient must be living in their own home, in a family member’s home, or in an assisted care facility – but not in a nursing home. 

All told, U.S. taxpayers are on track to spend around $231 billion on dementia care this  year. If the availability of a caregiver support program like Medicare’s were expanded to all eligible dementia patients, one estimate suggests it could save as much $21 billion over the next decade.   

Anne Tumlinson, CEO of ATI Advisory , a firm that consults on aging issues, questions whether the program will actually save money. “When you have a family member with dementia, your needs are bottomless,” she said. And whether these supports will keep most patients out of nursing homes is up in the air, too.

“It may help them a lot, and yet still not necessarily be the thing that prevents them from ultimately deciding, ‘You know what? I just can’t do this anymore. And I need a nursing home.’ ” 

Even with those limitations, the fact that Medicare will be starting to fund these sorts of programs at all is big news in the world of dementia care.

“I wept,” said Dr. David Reuben, Chief of Geriatrics Medicine at UCLA, describing how he felt when he heard about Medicare’s plan. “I wept because of all of the people around the country who are going to get the services they need paid for.”

Reuben directs UCLA’s Alzheimer’s and Dementia Care program , which includes a family caregiver component that is one of the models for Medicare’s pilot project. The UCLA model serves around 1,000 people right now, Reuben says, but without full payment from Medicare or other insurers, has been operating at a loss.

Medicare’s decision to pay for comprehensive care like this could spur interest among other insurers and hospitals, Reuben and other dementia experts say. Liz Fowler, of Medicare, said she’s already heard from hospitals and doctors interested in adopting some of the components of the program.

“Where goes Medicare, goes the rest of the country,” Fowler said. “That’s great news, because it means an expansion of this approach to care.”

‘The Hardest Thing I’ve Ever Done’

Family caregivers like Cindi Hart and Rosanne Corcoran say this sort of recognition and support are long overdue.

Since her mom died three years ago, at 92-years-old, Corcoran has led caregiver support groups organized by the nonprofit Daughterhood, and started a podcast on how to help a loved one through dementia.

“I absolutely adored my mother. I would have carried her on my back if I had to,” Corcoran said. “And it was still the hardest thing I’ve ever done.”trade

Tradeoffs’ coverage of Medicare sustainability is supported, in part, by Arnold Ventures.

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Episode resources.

Additional Reporting and Research on Dementia Care:

When Caring for Your Parents Comes at a Cost to Your Career (Clare Ansberry, The Wall Street Journal, 06/15/2024)

Applying An Evidence-Based Approach To Comprehensive Dementia Care Under The New GUIDE Model (Kristin Lees Haggerty, Gary Epstein-Lubow, et al, Health Affairs, 11/22/2023)

Guiding the GUIDE Model Toward Stronger Caregiver Supports (ATI Advisory, 09/2023)

Dementia Care Programs Help, If Caregivers Can Find Them (Judith Graham, KFF Health News, 02/27/2023)

Reducing the Cost and Risk of Dementia (Nora Super, Rajiv Ahuja, Kevin Proff, Milken Institute, 10/29/2019)

Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries (Lee Jennings, Alison Laffan, et al JAMA Internal Medicine, 12/21/2018)

A Family Disease: Witnessing Firsthand The Toll That Dementia Takes On Caregivers (Gary Epstein-Lubow, Health Affairs, 04/2014) 

Effectiveness of Collaborative Care for Older Adults With Alzheimer Disease in Primary Care (Christopher Callahan, Malaz Boustani, et al, JAMA, 05/10/2006)

Episode Credits

Malaz Boustani, MD, PhD , Founding Director, Sandra Eskenazi Center for Brain Care Innovation; Professor of Aging Research, Indiana University School of Medicine 

Rosanne Corcoran, Caregiver 

Liz Fowler , PhD, JD, Director of CMMI and Deputy Administrator, Centers for Medicare and Medicaid Services  

Cindi Hart, Caregiver 

Alex Olgin , Reporter/Producer, Tradeoffs 

Lauren Sullivan, Care Coordinator, Eskenazi Health

The Tradeoffs theme song was composed by Ty Citerman. Additional music this episode from Blue Dot Sessions and Epidemic Sound.  

This episode was reported by Alex Olgin and Dan Gorenstein, edited for by Deborah Franklin and mixed by Andrew Parrella and Cedric Wilson.

Additional thanks to: David Reuben, Anne Tumlinson, Jane Washburn, Rani Snyder, Gary Epstein-Lubow, David Bass, Jason Resendez and Sam Fazio,  the Tradeoffs Advisory Board, and our stellar staff !

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