Medicare provides the same level of coverage for urgent care as it does for emergency room services. Both types of care require you to pay coinsurance, copayments, and an annual deductible. Adding Medicare supplemental coverage may help you cover out-of-pocket costs, too.
Let’s learn more about Medicare’s role in covering urgent care treatment.
- Urgent care centers treat non-life-threatening illnesses and injuries that need immediate attention but don’t require emergency services.
- Medicare Part B covers 80% of the Medicare-approved amount for urgent care medical services.
- Medicare Part B coinsurance, copayments, and an annual deductible apply to urgent care services.
- Medigap, a Medicare supplemental coverage, can help pay Medicare copayments, coinsurance, and deductibles.
What Is Urgent Care?
Urgent care is the treatment of a condition, illness, or injury that isn’t severe enough to require emergency room care but does require immediate medical attention. It’s for problems that aren’t life threatening, but require medical attention within 24 to 48 hours. Typically, urgent care centers offer walk-in care that doesn’t require an appointment.
Urgent care can address conditions such as:
- Colds or flu
- Cuts that only require stitches
- Diagnostic services, like laboratory tests or X-rays
- Eye irritation
- Mild to moderate back problems
- Sore throat
Medical professionals who work in urgent care centers must hold a valid license to provide care. However, according to one study conducted by the Connecticut General Assembly’s Office of Legislative Research, the urgent care industry is largely unregulated, with only a few states requiring the facilities to obtain a special license to do business.
What Does Medicare Cover for Urgent Care?
Medicare Part B does cover urgent care services—or immediate medical care of a sudden illness or injury—to prevent disability or death in cases that aren’t a medical emergency.
Original Medicare covers 80% of the Medicare-approved amount of urgent care costs and you pay 20%. The Medicare-approved amount is an amount a medical professional or medical business agrees to accept from Medicare for services. Most doctors and other medical providers “accept assignment,” which means they have agreed to accept the Medicare-approved amount as payment in full.
If an urgent care center doesn’t accept assignment, you may have to pay all costs upfront, and you may pay more for services. If you pay out-of-pocket and the provider doesn’t submit a Medicare claim on your behalf, you may have to submit it yourself to receive reimbursement.
You can use Medicare’s provider search tool to verify whether a specific urgent care center accepts assignment or to find one near you that charges the Medicare-approved amount. You can also contact Medicare with questions online via live chat or by calling 1-800-MEDICARE.
Urgent care services are also subject to Medicare co-payments, typically a set amount like $20. If the provider doesn’t accept assignment, you’ll have to pay any amount that exceeds the Medicare-approved amount, which the law caps at 15% above what Medicare pays for certain services.
Additional Medicare Coverage for Urgent Care
Adding Medigap or to Original Medicare or switching to Medicare Advantage might help enhance your benefits, including Part B’s urgent care coverage.
Private insurance companies sell Medigap, a Medicare supplement that helps pay out-of-pocket Medicare costs, like copayments, coinsurance, and deductibles.
You can only buy Medigap coverage if you already have Medicare Part A and Part B. Medigap may also cover medical services received outside the United States, which isn’t covered by Original Medicare. If you carry Medigap and get sick or sustain an injury overseas, Medicare will pay the Medicare-approved amount of your medical costs and Medigap will kick in to pay its portion.
Medigap doesn’t cover Part B deductibles for new Medicare enrollees. However, if you’re just enrolling in Medicare, but were eligible before Jan. 1, 2020, you may be able to buy Part C and Part F coverages, which will cover the Part B deductible.
When you sign up for Medigap, you’ll pay a monthly premium to the private insurance provider and the monthly Part B premium to Medicare. Medigap only covers individuals, so spouses must carry their own policies. Medigap policies feature guaranteed renewal, so the insurer can’t cancel your coverage due to health problems.
Medigap policies sold after Jan. 1, 2006, don’t include prescription drug coverage. However, private insurers also sell Medicare’s prescription drug plan, Part D. While you can purchase Medigap and Part D coverages, carriers aren’t allowed to sell Medigap if you already carry a Medicare Advantage Plan (unless you’re switching back to Original Medicare.
You can compare plan benefits and see price estimates with the Medigap lookup tool from The U.S. Centers for Medicare and Medicaid Services. Once you find a plan you like, the tool provides a list of Medigap carriers in your area.
Medicare Advantage plans, also called “Part C” or “MA” plans, include Medicare Part A and Part B and are available through private companies. These types of plans cap annual out-of-pocket costs for covered medical services and most include Medicare Part D drug coverage.
Typically, Medicare Advantage Plans require you to seek medical services within a network. Common types of plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs), private fee-for-service (PFFSs), and special needs plans (SNPs). Some Medicare Advantage Plans allow you to seek non-emergency medical care, like from an urgent care center, out of network, but usually for a higher cost.
You can compare Medicare Advantage Plans using the plan lookup tool on the Medicare.gov website.
Urgent Care vs. Emergency Room Medicare Coverage
If you seek urgent care services, Medicare Part B covers 80% of the Medicare-approved costs and you’ll pay 20%, plus a copayment. The annual Part B deductible also applies to urgent care treatment.
Medicare Part B typically covers emergency room services. Medicare covers 80% of the Medicare-approved amount and you pay 20%. You must meet your annual Part B deductible and pay a copayment with each emergency room visit.
If within three days of your emergency room visit, your doctor admits you for inpatient care at the same hospital for the same medical problem, you won’t have to pay the emergency room copayment.
Medicare Part B also covers ground ambulance costs if you’re transported to a hospital or trauma center. In some cases, Medicare Part B also covers air ambulance transportation.
Know When Urgent Care Makes Sense
Generally, urgent care can handle medical issues that don’t risk disability and aren’t life-threatening. Conditions that might warrant a trip to an urgent care center might include common illnesses such as colds, earaches, the flu, low-grade fevers, migraines, and sore throats.
Urgent care professionals can deal with minor injuries, like back pain, minor broken bones, minor cuts, minor eye injuries, and sprains.
For major illnesses or serious injuries, call 911. That could include:
- Alcohol or drug overdoses
- Breathing problems
- Coughing up or vomiting blood
- Head injuries that cause confusion, fainting, or passing out
- Severe neck or spine injuries
- Severe allergic reactions that cause breathing difficulty, hives, or swelling
- Heavy bleeding or bleeding you can’t control
- Moderate or severe burns
- Smoke inhalation
- Sudden confusion or an inability to move, see, speak, or walk
- Sudden severe headaches
Frequently Asked Questions (FAQs)
What does Medicare define as urgent care?
Medicare defines urgent care as a condition, illness, or injury that isn’t severe enough to require an emergency room visit, but one which any reasonable person would consider serious enough to seek immediate medical attention.
How much is the co-pay for urgent care with Medicare?
If you need urgent care treatment, you’ll pay 20% of the Medicare-approved amount for doctor fees and medical services. You must also meet an annual Part B deductible, which was $203 in 2021. After meeting the deductible, you’ll pay 20% of the Medicare-approved amount for most doctor and outpatient services.