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Is Urgent Care Covered by Medicare?

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Is Urgent Care Covered by Medicare?

writtenByWritten by: Christina Wedberg
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.

Read more posts by this author.
reviewBy Reviewed by: Leann Poston, M.D.
Reviewer

Leann Poston, M.D.

Leann Poston, M.D. earned her medical degree from the Wright State University Boonshoft School of Medicine. She completed an MBA from Raj Soin College of Business, focusing on healthcare. She is a full-time medical communication writer and educator.

June 3, 2021 Read Time - 6 minutes

Does Medicare Provide Coverage For Urgent Care?

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 Medicare covers them.

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  • Use your health insurance just like you normally would to see your doctor.

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What Qualifies as Urgent Care?

According to the American Academy of Urgent Care Medicine: “Urgent Care services are medically necessary services which are required for an illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have the potential to develop such a threat if treatment is delayed longer than 24 hours.” 

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 covering 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 a Medicare Advantage Plan 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, meaning 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 additional 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. You will show your Advantage Plan card to receive health services, including urgent care.

Physicians May 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 do not.

Doctors who do not take Medicare insurance may ask patients to sign a contract stating that they 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 paperwork.

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 predetermined fee schedules, which gives no discrepancy for filing your claim.

  • Book on our free mobile app or website.

    Our doctors operate in all 50 states and same day appointments are available every 15 minutes.

  • See a doctor, get treatment and a prescription at your local pharmacy.

  • Use your health insurance just like you normally would to see your doctor.

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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.

Appointments as low as $20.

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What is the Copay for Medicare Urgent Care?

You may find yourself asking, “What does Medicare pay for urgent care?” First, you’ll want to ensure that the urgent care center 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 for paying the remaining 20 percent either out-of-pocket or with co-insurance after you’ve met the Medicare Part B deductible, which is $185 as of 2019.

  • Book on our free mobile app or website.

    Our doctors operate in all 50 states and same day appointments are available every 15 minutes.

  • See a doctor, get treatment and a prescription at your local pharmacy.

  • Use your health insurance just like you normally would to see your doctor.

PlushCare-App-Steps

Does Medicare Include Online Urgent Care Coverage?

If your Medicare plan covers telemedicine, you will be covered. If not, you will have to pay out of pocket. Thankfully, online urgent care is affordable, even without Medicare coverage. 

An appointment at PlushCare costs only $119. 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? Book an appointment online with a physician and see a doctor today.


Read More About Getting a Prescription Online:


Sources:

PlushCare is dedicated to providing you with accurate and trustworthy health information.

American Academy of Urgent Care Medicine. What is Urgent Care Medicine? Accessed on May 20, 2021 at https://aaucm.org/what-is-urgent-care-medicine/

Mount Sinai. What is Urgent Care and When Should You Use It? Accessed on May 20, 2021 at https://www.mountsinai.org/locations/urgent-care/what-is-urgent-care

Centers for Medicare and Medicaid Services. Urgently needed care. Accessed on May 20, 2021 at https://www.medicare.gov/coverage/urgently-needed-care

Most PlushCare articles are reviewed by M.D.s, Ph.Ds, N.P.s, nutritionists and other healthcare professionals. Click here to learn more and meet some of the professionals behind our blog. The PlushCare blog, or any linked materials are not intended and should not be construed as medical advice, nor is the information a substitute for professional medical expertise or treatment. For more information click here.

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