Urgent Care, Emergency Room or Your Doctor? Where to Go and What Medicare Covers

When to call 911

Some symptoms need emergency care without delay. Two examples from the CDC:

Heart attack

The CDC's page on heart attack symptoms lists chest pain or discomfort, usually in the center or left side of the chest, that lasts more than a few minutes or goes away and comes back; feeling weak, light-headed or faint, sometimes with a cold sweat; pain or discomfort in the jaw, neck or back; pain or discomfort in one or both arms or shoulders; and shortness of breath. It says to call 911 immediately if you notice these symptoms in yourself or someone else.

Stroke

The CDC's page on stroke signs lists sudden numbness or weakness in the face, arm or leg, especially on one side of the body; sudden confusion, trouble speaking or difficulty understanding speech; sudden trouble seeing; sudden trouble walking, dizziness, loss of balance or lack of coordination; and a sudden severe headache with no known cause. Its B.E. F.A.S.T. check asks about balance, eyes, a drooping face, a drifting arm and slurred speech, and the T stands for time: if you see any of these signs, call 911 right away. The CDC also advises noting the time the symptoms first appeared, because it helps health care providers decide on treatment.

A mental health crisis

The 988 Suicide & Crisis Lifeline is free, confidential and available 24 hours a day by call, text or chat. If someone is in immediate danger, call 911.

These lists are examples, not a complete guide to emergencies. If you think something is an emergency, do not wait for an appointment or a callback.

Emergency departments

Medicare.gov's emergency department page describes emergency services as services you get in a hospital emergency department when you have an injury, a sudden illness or an illness that quickly gets much worse.

What hospitals must do

Under the Emergency Medical Treatment and Labor Act (EMTALA), CMS's EMTALA page explains, Medicare-participating hospitals that offer emergency services must provide a medical screening examination when someone asks for examination or treatment for an emergency medical condition, including active labor, regardless of ability to pay. If there is an emergency medical condition, the hospital must provide stabilizing treatment, or an appropriate transfer if it cannot stabilize the patient within its capability or the patient requests it.

Getting there

Medicare.gov's ambulance page says Part B covers ground ambulance transportation when traveling in any other vehicle could endanger your health and you need medically necessary services from a hospital, critical access hospital, rural emergency hospital or skilled nursing facility. Medicare covers the trip only to the nearest appropriate medical facility that can give you the care you need. Air ambulance may be covered when you need immediate and rapid transport that ground transportation cannot provide.

Urgently needed care

Medicare.gov's urgently needed care page describes it as care to treat a sudden illness or injury that is not a medical emergency or life-threatening. Part B covers it. Where you get it matters for the bill:

• Your own clinician's office: the office knows your history and medicines. Ask your office, before you need it, whether it has same-day appointments or an after-hours line.
• An urgent care center or walk-in clinic: useful when your office is closed or has no openings. Ask whether the center accepts your coverage, and whether it is part of a hospital, because that changes what you pay (see below).
• A telehealth visit: some problems can be handled by video or phone. Medicare.gov's telehealth page says that through December 31, 2027, Medicare covers telehealth services you get from anywhere in the U.S., including your home. Our telehealth guide explains how visits work and what to check first. A clinician may still need to see you in person.

If an urgent care clinician thinks your problem is an emergency, they may send you to an emergency department.

What Original Medicare covers and what you pay

The amounts depend on the setting. Medicare.gov describes them this way:

• Emergency department: you pay a copayment for each emergency department visit and a copayment for each hospital service you get. After you meet the Part B deductible, you also pay 20% of the Medicare-approved amount for your doctor's services. If your doctor admits you to the same hospital for a related condition within 3 days of the emergency department visit, you do not pay the copayments, because Medicare considers the visit part of your inpatient stay.
• Urgently needed care: after you meet the Part B deductible, you pay 20% of the Medicare-approved amount for the doctor's or other health care provider's services. In a hospital outpatient setting, you also pay a copayment.
• Ambulance: after you meet the Part B deductible, you pay 20% of the Medicare-approved amount.
• Office visits: Medicare.gov's page on doctor and other health care provider services says that after you meet the Part B deductible, you pay 20% of the Medicare-approved amount for most services.

Medicare.gov's emergency department page also notes that Medicare only covers emergency services outside the U.S. in rare situations. If you travel abroad, check other coverage before you go.

Whether the clinician accepts assignment

In an office or urgent care center, your share is lowest when the clinician accepts Medicare assignment. Our assignment guide explains why.

If you have a Medicare Advantage plan

Medicare Advantage plans have networks. Medicare.gov's comparison of Original Medicare and Medicare Advantage says you may need to use doctors and other providers in the plan's network and service area for non-emergency care. Medicare.gov's HMO page lists emergency care and out-of-area urgent care among the services an HMO covers outside its network. Costs for emergency and urgent care differ from plan to plan, so check your plan's documents or call the number on your card.

Plan ahead before you need care

A few minutes now can save time later:

1. Save your primary care office's number and ask how it handles same-day and after-hours problems.
2. Find the urgent care centers and the hospital emergency department closest to you, and check which ones your coverage includes.
3. Keep a current list of your medicines, allergies and conditions in your wallet or phone.
4. Know how to reach 911 and 988, and make sure people close to you know them too.

If you do not have a regular clinician, our primary care guide explains how to find one. On T-MedInfo you can browse clinicians by city from the city listings below, including family medicine, internal medicine and nurse practitioner listings. Our listings show clinicians at an address in your area; they do not show opening hours, wait times or whether a practice takes walk-in patients, so call before you go.