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Is Urgent Care Covered by Medicare?

If you have an accident or a sudden illness, you may wonder if Medicare will cover your trip to an urgent care center. The answer is mostly yes, but it's a question with a complex answer that has a few different possibilities. Read on to learn more about the basics of urgent care centers and when they are covered by Medicare.

What is Urgent Care?

Urgent care centers offer convenient, extended hours and locations for patients who may need healthcare when their regular physician’s office is closed or unable to give a timely appointment. Urgent care centers also provide immunizations that cover anything from a flu shot to immunizations for a trip out of the country. While some people may choose to go to an emergency room if they think they have a broken bone or a fracture, many urgent care centers have x-ray machines that provide the same services for less expense and quicker service.

What is Medicare?

Medicare is a U.S. federal government program run by the Centers for Medicare & Medicaid Services (CMS). It’s funded partly by Medicare taxes that you pay on your income, Social Security taxes, and from funds out of the federal budget. It provides your health care coverage if you are:

  • Over 65 years old
  • Under 65 and receive Social Security Disability Insurance (SSDI)
  • Under 65 with End-Stage Renal Disease (ESRD)

Once you are eligible for Medicare, you can choose to enroll from either the traditional Original Medicare program that offers fee-for-service benefits through the federal government, or from a Medicare Advantage Plan that are offered by private insurance companies that contract through the federal government.

Original Medicare has two main options:

  • Medicare Part A – Covers inpatient hospital services
  • Medicare Part B – Covers outpatient medical services

There is also Medicare prescription drug coverage (Part D) available. However, in most cases, you need to join a standalone private drug plan (PDP) for this option.

Understanding Medicare Coverage

It’s important to understand which choices you have when picking your Medicare coverage. This will affect your out-of-pocket costs and where you can get your health care. For example, with Original Medicare, you will have coverage to choose nearly any doctor or hospital in the U.S.

With Medicare Advantage, however, there may be network restrictions and that means that you may be limited in your choices of access to hospitals, urgent care centers, and doctors. On the other hand, Medicare Advantage Plans may also provide other benefits that Original Medicare doesn’t usually cover, such as routine dental and vision healthcare.

Everyone that qualifies for Medicare receives an Original Medicare card that is red, white, and blue. When you receive healthcare, whether at an urgent care center, a physician’s office, or an emergency room, you will show this card to get your services.

If you choose to get your healthcare coverage through a Medicare Advantage Plan, you will get both an Original Medicare card and a membership card from your Advantage Plan and you will show your Advantage Plan card to get health services, including urgent care.

Some Physicians Opt-Out of Medicare

Although uncommon, some urgent care doctors may choose to opt out of treating patients who carry Medicare insurance. In some cases, urgent care centers will have on staff both doctors that treat Medicare patients and some that don’t.

Doctors that don’t take Medicare insurance may ask patients to sign a contract that states the patient will not file a claim with Medicare for their services. But according to a federal regulation that went into effect in January 2013, patients can still be treated by these opt-out physicians. The patient will not experience any issues, but the physician will be subject to more paper work.

Patients that do get treated by a doctor at an urgent care center that accepts Medicare may find that they will have less hassle filing their claims and pay lower fees. Most of these doctors have set up pre-determined fee schedules, which gives no discrepancy for filing your claim.

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Emergency Room Care Vs. Urgent Care

Emergency room care and urgent care are both covered by Medicare Part B on an outpatient care basis. There are some advantages to choosing to receive your care at an urgent care center rather than the emergency room:

  • Shorter wait times
  • Lower cost
  • Individualized care

Urgent care centers are usually staffed by doctors, nurses, and physician’s assistants. As long as your illness isn’t life threatening, going to an urgent care center versus an emergency room can save you time and money.

What is the Copay for Medicare Urgent Care?

You'll want to make sure that the urgent care center that you go to will participate in your specific Medicare plan. Typically, your Medicare insurance will cover about 80 percent of services that are Medicare-approved. You’ll be responsible to pay the remaining 20 percent either out-of-pocket or with co-insurance after you’ve met the Medicare Part B deductible (which is $185 in 2019).

Will Medicare Cover Online Urgent Care?

It depends. If your medicare covers telemedicine, you will be in good shape. If not, you will have to pay out of pocket.

Luckily, online urgent care is super affordable. An appointment at PlushCare costs only $99. Through online urgent care services like PlushCare, you can see a doctor and get a prescription sent straight to your pharmacy without leaving your home!

Think you may be interested in an online urgent care appointment? Click here to book an appointment with a PlushCare physician and see a doctor today!

PlushCare takes content accuracy seriously so we can be your trusted source of medical information. Most articles are reviewed by M.D.s, Ph.D.s, NPs, or NDs. Click here to meet the healthcare professionals behind the blog.

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Christina Wedberg

Christina Wedberg

Christina has been a writer since 2010 and has an M.F.A. from The New School for Social Research. Christina specializes in writing about health issues and education.

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