Emergency medical condition: Symptoms severe enough that someone with an average knowledge of health and medicine could reasonably expect your health to be in serious danger if you don’t get medical attention right away.

Urgently needed care: Medically necessary and immediately required as a result of an unforeseen illness, injury, or condition. Not reasonable for you to wait to get needed care.

Note: These definitions are especially important if you have a Medicare Advantage Plan! There are certain protections for you if you need emergency or urgent care outside of your plan’s network.

 

Emergency Room Services

Original Medicare covers emergency room services anywhere in the U.S.

Medicare Advantage Plans must also cover emergency room services anywhere in the country. Your plan cannot make you see an in-network provider or get a referral. It must also cover needed follow-up care related to the medical emergency if delaying it would endanger your health. You have the right to appeal if your plan does not cover your emergency care.

Note: If your condition was not an emergency but appeared to be an emergency, your care must still be covered. For example, let’s say you have chest pain and think you could be having a heart attack. If you go to the emergency room and doctors discover that your pain is heartburn, your care should still be covered because the situation appeared to be an emergency.

 

Ambulance coverage

Medicare covers emergency ambulance services. (In limited cases, it covers non-emergency ambulance services.) Medicare considers an emergency to be any situation when your health is in serious danger and you cannot be transported safely by other means. If your trip is scheduled when your health is not in immediate danger, it is not considered an emergency.

Note that the ambulance is only covered if it takes you to and from certain locations. For example, from any place where need arises to the nearest appropriate hospital.

 

Emergency care outside the U.S.

Medicare usually doesn’t cover medical care outside the U.S. However, Original Medicare and Medicare Advantage must cover care in certain circumstances:

• You get emergency care in Canada while traveling a direct route, without unreasonable delay, between Alaska and another state, and the closest hospital that can treat you is in Canada.
• You get emergency care on a cruise ship while the ship is in U.S. territorial waters. This means the ship is in a U.S. port or within six hours of a U.S. port.
• You get emergency care in a foreign hospital that is closer to your residence than the nearest available U.S. hospital. This may happen if you live near the border of Mexico or Canada.

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