What Can People with Medicare Expect from an Emergency Room Visit?

As a contractor for Medicare, Acentra Health serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Acentra Health provides BFCC-QIO services in 29 states, the general information is relevant to everyone who has Medicare (including Medicare Advantage) and everyone who works with people who have Medicare. 

This episode is a conversation with our guest from Acentra Health: Dr. Angeline Brunetto, Associate Medical Director for Appeals

In this podcast, our guest will share information about what Medicare beneficiaries can expect from a visit to the emergency room.

For more information about Acentra Health BFCC-QIO, please visit www.acentraqio.com.

KEY TOPICS 

00:22: Overview and introduction

01:04: The emergency room experience

03:56: Medicare coverage

08:18: Key things to know about an emergency room visit

10:06: Tips for people with Medicare

12:03: Myths and misunderstandings

13:54: Summary and final thoughts

SUBSCRIBE 

Subscribe to our newsletters: Case Review Connections, On the Healthcare Front at our website, www.acentraqio.com

RESOURCES

BFCC-QIO Information for stakeholders: www.acentraqio.com/partners

BFCC-QIO Information for people who have Medicare: www.acentraqio.com/bene

YouTube channel - https://www.youtube.com/@AcentraBFCCQIO

Music: Motivational Upbeat Corporate by RinkevichMusic 

https://soundcloud.com/rinkevichmusic

https://protunes.net/

Video Link: https://bit.ly/3NNqGTs

Transcript

Welcome to Aging Health Matters, a podcast from Acentra Health, a Beneficiary and Family Centered Care Quality Improvement Organization. We plan to cover healthcare topics for the Medicare population. Information in today's show may help you or someone you know in their healthcare journey. Thanks for joining us. Now let's get started.  

Hi, everyone. I am Dr. Angeline Brunetto. I'm an Associate Medical Director for Appeals, and I will be your host today for Aging Health Matters. Acentra Health is the Beneficiary and Family Centered Care Quality Improvement Organization for 29 states. We help people with Medicare who have concerns about their health care. We can help you appeal if you're leaving the hospital too soon or if skilled services like physical therapy are ending too early. We also offer Immediate Advocacy services to help fix problems quickly with medical care or services. More information is available on our website at acentraqio.com. 

Today we are going to be talking about emergency room visits and helping Medicare beneficiaries and their families understand what happens when you go to the emergency room and how those costs are covered. So a quick reminder, this is not specific medical or financial advice. So let's talk about the emergency room experience. When someone goes to the emergency room, it's not usually because they feel great. There's something going on. They don't feel well. They may be hurting or in pain, have an injury, or are sick. So it can be a scary time for most people. Now, regardless of how you arrive to the emergency room, the first thing that should happen is the triage process. That means someone in the medical community is going to examine you. Usually, it's a nurse. They're going to do a quick assessment of what's going on with you and help determine how urgent your situation is. Once you're actually back into the room, or even if you're in the waiting room, you're going to go through a registration process. Registration is someone who's going to come, and they're going to want to get a copy of your ID to see who you are, a copy of your Medicare card, and any supplemental insurance information that you have. So it's always important to have those with you when you go to the emergency room.
 
Now once you're in the emergency room and being assessed, you're going to have a medical evaluation. That can be performed by a physician assistant, a nurse practitioner, or a doctor. They're going to do a physical exam, talk to you, determine what's going on, maybe do diagnostic testing, such as lab work or x-rays if needed, and help determine what's going on with you. And then your treatment plan should be initiated as well. Do you need medications? Are you going to be admitted to the hospital? Do you get to go home? So you can expect to be assessed, maybe have testing, and then treated. 

When your emergency room experience is completed, there's going to be three outcomes. You get to go home. So maybe you had a minor injury or don't have anything that's seriously wrong, and the doctor or the provider determines that your medical care can be managed at home, then you're discharged. You get to go home from the emergency room. Or they may decide that, hey, we need to observe you for a little while. We want to make sure that you continue to do better, and they may admit you to the hospital as an observation, meaning they're just keeping an eye on you. Or if you're really sick or if you are seriously injured, then you may need to be admitted to the hospital for a true inpatient admission.
 
And what that means is that you're going to get medical treatment while you're there in the hospital, and they expect you to be there for at least a couple of days.  So how does Medicare cover the emergency room visit and the hospital stay? So we all know that understanding Medicare can be complicated and confusing, and it's not just for beneficiaries, it can be for the medical community as well. So let's break it down.

There are several parts to Medicare. So the first part is Medicare Part A, and that is known as the hospital insurance, or you can actually refer to it as that. This is the hospital insurance portion of Medicare that helps cover the costs for inpatient hospital stays. So I mentioned already that if you're really ill or if you have a serious injury and you're admitted to the hospital as an inpatient receiving treatment there, then the Medicare Part A covers that part of the costs that are involved. Now deductibles do apply, and your cost is roughly $1,600 per benefit period before Medicare starts to pay. 

So if you're admitted to the hospital as an inpatient, a true admission, then you can expect that your deductible will probably be in the area of $1,600, and then Medicare Part A should help cover the rest of that. OK, so that's Part A. So you probably heard of Medicare Part B. Part B is the medical insurance. So what that covers is all those things as an outpatient. Think of when you go to the doctor's office for a visit or a clinic or you have blood tests done as an outpatient or even the emergency room. So when you're an outpatient and not truly admitted to the hospital as an inpatient, that's when Medicare B covers.
 
They cover medical services and supplies. They can cover the emergency room visit for injuries or sudden illnesses. So they'll cover the doctor services, those tests, and the treatments. We had talked about if you're discharged from the emergency room and you're not admitted to the hospital, you will have an annual deductible, which means about once a year you're expected to pay about $257. And then once that deductible is met, when you go to the emergency room after that, you have about a cost share, about 20% of the Medicare allowable. So once your deductible is paid and you receive the bill, your portion is about 20% of those costs.
 
Now there is a supplemental insurance that can be purchased, and it's called Medigap, and that's a private insurance, and it's sold through private insurance companies, and that supplements Original Medicare. So Original Medicare Part A and Part B, and it helps cover those gaps in coverage. Now that means those out-of-pocket expenses such as co-insurance, co-payments, and your deductibles that aren't ordinarily covered by Medicare. It's getting tricky, isn't it? All right.
 
Now you have a Part A, and you have a Part B, which we talked about. Part C. So Part C is a little bit different. It is private insurance through an insurance company as well, but they manage the Part A and Part B combined together. So these are usually known as Medicare Advantage plans, and they are managed through private insurance companies like I stated. So what that means is that the Medicare Advantage plan covers your emergency room visit and the services too, but those costs can be different than original or traditional Medicare, meaning you're really going to need to check with the company and the plan that you have. So contact your plan to understand what coverage rules and co-payments may apply because they can be different from company to company.
 
All right. So now we're up to Part D. Part D is the drug coverage. So that means your prescriptions and things like that that you may receive after you go to the emergency room. So Part D covers medications that are prescribed during or even after the emergency room visit. They're filled at a pharmacy. So that covers the main parts of Medicare. So you may want to even probably even listen to that again because it can be confusing. 

The four key things to know when you go to the emergency room is that Medicare covers emergency room visits anywhere in the US, and that's especially true if it's a true medical emergency. Now that's for Original Medicare, and that is also for the Medicare Advantage plans. Now the next thing to know is observation status versus admission. Now we talked about that if they decide to keep you in the hospital for observation, just to make sure that you're doing OK, that's an observation status, and it's not a true inpatient admission, which means that your cost differences are going to be applied there, and you might even be surprised because as an outpatient, your copay may actually end up being more.
 
Now, if you're concerned about out-of-network, now the Medicare Advantage plans, they will actually have preferred providers or hospitals that they want you to go to. If you have a true medical emergency, don't worry about what emergency room that you're going to. If it's a true medical emergency, you don't have to worry about out- of-network charges because it's going to be covered even outside of the plan's network. Now we had also talked about how you get to the emergency room. 

If you go by ambulance, Medicare Part B, the medical coverage, covers the ambulance ride if it's medically necessary. There may be a coinsurance that needs to be paid along with that, but it should be covered by Part B, the medical insurance. Also to know the Medicare Advantage plans also cover ambulance rides if they're medically necessary. And again, you're going to have to reach out to your plan to see what your cost share will be with that.
 
All right, so some tips. We kind of touched on that already. Always carry your Medicare card and your supplemental insurance card. Just always have it with you. Always have a copy of it. If you have a Medigap, that's supplemental insurance or a Medicare Advantage plan, know your coverage. It's going to impact how much money you are expected to pay because once you go to the emergency room, you're more concerned with getting better or having your injury treated. You're not really thinking about how those costs will impact you. But it's important to know what you have so that even afterwards, you can know what to expect when those bills arrive.

If you are admitted to the hospital, it's important to know what your admission status is. You can even ask them, am I being observed, or is this a true inpatient admission to the hospital? Again, your cost share is going to vary depending on the status of your admission. Just because you spend the night doesn't mean that it's a true inpatient admission. You can actually spend the night and still be observed. Now, after you're home, it usually takes a while, but you're going to get some bills in the mail or even a summary of your benefits. And it's going to outline what services you received, what treatments that you had, and the breakdown of those costs. And sometimes that paperwork can be daunting.  

So I do recommend that you still take a look at it. If you see that there's something on there that you don't remember receiving or that doesn't apply to you, you are definitely within your rights to question the hospital or even the insurance company about that and say, you know, hey, this doesn't look right. Errors can occur, and it's important to have those removed if they don't apply to you. So follow up on those bills and ask about charges or disagree with something if it's not correct.
 
Now let's move on to those common myths and misunderstandings. So Medicare covers everything in the ER. Not true. Cost sharing still applies. Doesn't matter if it's Original Medicare or even a Medicare Advantage plan. Again, so understand your coverage. Another common myth and misunderstanding. If I'm kept overnight, I'm automatically inpatient. Not always. We talked about that you can still be observed in the hospital under an observation status and not be a true inpatient or true admission. It's important to know that as well, so you know what to expect. Another concern, I'll get surprise bills for emergencies. Now that's less likely with Medicare, but possible if per chance, the doctor doesn't accept Medicare assignment. But to be honest, from the emergency room perspective, if it's a true medical emergency, it should be covered because most of those providers that are going to be in the emergency room are accepting Medicare, but important to know. 

We've covered a lot of things. Medicare and understanding the different parts is especially, like I said, confusing and sometimes hard to wrap around, but the key takeaways: An emergency room visit is covered under Original Medicare and Medicare Advantage plans. So if you have a true emergency, you do need to go. You do need to go to the emergency room, be treated, be seen, but understand that depending on which plans that you have, your costs may vary depending on the coverage type that you have. Also, supplemental coverage can make a big difference in out-of-pocket costs, so be aware of what you have if you have Medigap and what the coverages are for Medicare Advantage. 

To wrap this up, if you'd like more personalized information, you can contact your Medicare Advantage insurance company or consult medicare.gov for Original Medicare information. If you would like more information about our services, please feel free to sign up for our newsletter as well as subscribe to our YouTube channel. Our helpline phone number as well as the link to our website to sign up for our newsletter will be in the Show Notes. Thank you so much for listening, and please stay tuned for our next episode of Aging Health Matters. Have a great day.