Does Medicare Cover Urgent Care?

Medicare Benefits Solutions

Nov 20, 2020

We’ve all been there — we feel sick, but we know it’s not life or death, so going to the emergency room seems dramatic. But, it might be after-hours, or your regular doctor may not be available and you still need to be seen now, not later. Enter urgent care. These facilities bridge the gap between the life-saving purposes of often crowded emergency rooms and the lack of availability of most primary care physicians on short notice.

The good news is that, in addition to regular doctor appointments, Medicare Part B should cover an unexpected visit to an urgent care center. You may want to verify that the facility you are going to accepts Medicare and you are still responsible for any coinsurance or deductible costs according to your specific plan benefits.

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What Conditions are Treated at Urgent Care?

Anything short of an acute, life-threatening condition can usually be treated at an urgent care center. And here’s the good news, urgent care is typically associated with lower costs and shorter waiting times compared to a visit to the emergency room.

The problem is, you might not realize if what you’re experiencing is something serious that warrants rushing to the hospital, instead. That’s why most urgent care centers will offer you a brief questionnaire to help you review your symptoms. 

Conditions treated at most urgent care centers include:

  • sprains
  • cold or flu
  • allergies
  • insect and animal bites
  • minor cuts and scrapes
  • UTI and other bacterial infections

Generally, you can expect providers at urgent care to advise you to seek out emergency treatment at a hospital if you’ve been in an accident or your symptoms are severe or excessive. Do you have a sore throat? Urgent care can probably help you. Are you struggling to breathe? That justifies a trip to the emergency room. If you measure the severity of your pain or symptoms by a similar scale, you can better understand what you might have treated at an urgent care center.

When to visit the ER:

  • heart attack
  • stroke
  • head injury
  • seizures
  • broken bones
  • serious bones
  • uncontrolled bleeding
  • suicidal thoughts

Despite its name, urgent care centers can also provide routine exams, vaccines and medical waivers as part of their services. These may be available only by appointment or during certain seasons, and you may need to check if your insurance covers that treatment when given at an urgent care center versus your primary care physician. It’s possible the urgent care center will need verification from your primary care physician that they are not available for an appointment in order for your urgent care center to be able to bill for your care, instead.

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Medicare Coverage for Urgent Care

With Original Medicare, you’ll be covered under Medicare Part B policy rules for an urgent care visit. This means you’ll have your yearly deductible to meet if you haven’t met it yet, as well as a 20% coinsurance to pay. If you have a Medigap or Medicare Advantage plan, the monthly premium you pay to that plan may mean out-of-pocket expenses at the point of service are already covered. The same applies if you have dual eligibility with Medicaid. 

Medicare Part B may also cover the cost of diagnostic work done on-site or any medication that is administered by the doctor or nurse on duty. Your healthcare specialists at the facility can help you determine what services may be covered or not if you’re in doubt, but Medicare can also reimburse you for costs that should have been covered but may have been billed to you directly.

If you need urgent care while out of the country and have Original Medicare, only certain Medigap plans with travel coverage will help you mitigate those bills. The last thing you need when you’re looking for urgent care away from home is to worry about the bill. There are some pretty particular rules about when overseas coverage can apply, so make sure you read up on those conditions before you travel.

If you’re enrolled in a Medicare Advantage (MA) plan, you will have at least the same benefits as Original Medicare. Many MA plans include additional coverage, as well. Check with your plan directly to find out details about your urgent care coverage.

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