What to Know About Medicare and Urgent Care

• An urgent care center provides outpatient care for sudden illnesses and injuries. 

• Emergency rooms, primary care physicians, and retail clinics provide similar services to urgent care, but each facility has its capabilities.

• Understanding the federal Medicare program makes navigating unforeseen circumstances easier. Discussing options with a licensed insurance agent or a licensed health insurance agency may be helpful.

An urgent care center is a type of ambulatory care clinic that provides outpatient healthcare services for issues that require prompt medical attention. These centers usually do not require a referral. As such, Medicare beneficiaries can visit in-network urgent cares on a walk-in, outpatient basis.

Urgent care centers provide diagnostic, observational, consultative, and treatment services for a variety of ailments. Health concerns that can be handled by urgent care are not life-threatening or do not pose the threat of disability, if not taken care of immediately. However, urgent care services are considered to be medically necessary, requiring professional intervention to properly resolve. 

Types of Providers

An urgent care is staffed by several different healthcare professionals, including:

• Physicians (MD or DO) 

• Nurse practitioners

• Physician assistants (PA)

• Registered nurses

• X‑ray technicians

• Medical assistants

Benefits of Urgent Care Centers

There are several benefits, including:

• No appointments needed

• Most open earlier, or later, than other healthcare facilities

• Less costly than emergency room 

• Shorter wait times than the emergency room

An urgent care center is one option for receiving urgent healthcare services. That said, there are several other medical facilities a Medicare beneficiary may consider, including emergency rooms, retail clinics, and/​or primary care. 

Determining which medical facility is most appropriate is not always clear to Medicare beneficiaries which is why understanding the purpose and out-of-pocket costs for each one is vital.

Emergency Room (ER)

An ER is the department of a hospital that provides emergency medical care for critical health situations. An ER doesn’t require an appointment, but care is usually administered based on severity. 

Emergency department services include: 

• Diagnostics (Blood work, X‑rays, MRIs and CT scans, etc.) 

• Ambulance services

• Emergency surgery

• Inpatient stays

An ER accepts Medicare. To learn more about emergency coverage, ER costs, and Medicare, visit this resource.

How to Choose Between Urgent Care and ER 

The main difference can be found within the names themselves: urgent care and emergency room. Urgent cares provide medically necessary healthcare services for urgent medical issues, meaning that patient complaints require healthcare professional insights and care for them to resolve. The ER, on the other hand, is reserved for medical emergencies, meaning someone’s life is at risk, or there is the chance of disability, if not immediately addressed. If you need to visit the ER, please call 911.

The best way for a patient to decide whether to seek treatment at urgent care or the ER is to determine if what they are experiencing is medically urgent or a medical emergency. How that question is answered will determine which care facility is needed. 

Medical Emergency Conditions:

The below conditions are considered emergency conditions, warranting a trip to the ER:

• Heart attack symptoms (shortness of breath, chest pain,) 

• Stroke symptoms (slurred speech, change in mental state, weakness on one side)

• Heavy bleeding

• Severe abdominal pain 

• Severe broken bones or fractures

• Severe burns

• Seizures

• Fainting or loss of consciousness

• Head injury or a concussion

• Large lacerations requiring a large number of stitches

Urgent Medical Conditions:

• Minor accidents and falls

• Sprains and strains

• Fever

• Flu

• Eye irritation

• Bleeding or cuts that may require a small number of stitches

• Sore throat

• Cough and other minor respiratory symptoms 

• Gastrointestinal problems (nausea, vomiting, diarrhea) 

• Minor broken bones or fractures (fingers or toes) 

• Skin rashes and infections

• Urinary tract infections (UTIs)

Retail Clinics

A retail clinic provides healthcare services for common health conditions. These clinics are staffed by nurse practitioners and/​or physician assistants. There are around 1,200 retail clinics in the United States.

The main purpose of a retail clinic is to quickly administer care for less complex, non-urgent health problems. Retail clinics also provide preventative services, such as vaccinations. 

Note: To know more about retail clinics and Medicare coverage, visit this resource.

How to Choose Between Urgent Care and Retail Clinics

Retail clinics are not equipped for pressing medical events, for example, lacerations, broken bones, sprains, etc. Situations such as those are more fit for urgent care or ER. 

Retail Clinic Medical Conditions: 

• Strep throat

• Pink eye

• Sinus infection

• Flu

Primary Care Physician (PCP)

A PCP is a doctor who coordinates and manages healthcare for their given group of patients. They address a range of healthcare matters. A PCP knows the patient history and is best for chronic, non-acute, medical problems that require making an appointment.

Note: To learn more about PCPs, visit this source.

How to Choose Between Urgent Care and PCP

Since a PCP is appointment-based, these types of doctors are best used for chronic medical issues. Since they’re less flexible, urgent matters are best served by urgent care. And, again, emergency conditions should be treated by an ER.

Primary care physician medical conditions:

• Annual physical exams

• Preventative boosters and vaccines

• Mild fever

• Minor aches and pains

• A lingering cough or cold

Original Medicare insurance is made up of Medicare Part A and Medicare Part B. Medicare Part B, the medical insurance portion, covers healthcare services for treating sudden, non-emergency illness or injury. This includes urgent care, though the urgent care facility must be in-network. Patients should contact the urgent care clinic before visiting to ensure it accepts Medicare. 

Medicare Part B covers two types of services: medically-necessary services and preventative services. Coverage starts once the yearly deductible is met. In 2021, the deductible is $203.

Once that is met, Medicare beneficiaries must pay 20% of their Medicare Approved amount of the urgent care visit. The Medicare-approved cost refers to the amount a healthcare provider can be paid. It may be less than the actual number charged. Medicare pays for part of the amount, and the patient is responsible for paying the difference. In a hospital outpatient setting, you also pay a copayment. 

Those with a Medicare Advantage Plan, also known as Medicare Part C, include Medicare Parts A, B, and D, as well as other benefits such as dental, vision, or hearing insurance. 

Since a Medicare Advantage Plan also includes Medicare Part B, this means that many Medicare Advantage plans will provide coverage for urgent care visits. However, again, the facility chosen must be in the plan’s network, otherwise, patients may pay additional urgent care costs. 

Medicare supplement insurance plans, known as Medigap, is the Original Medicare supplement policy that may help reduce or cover out-of-pocket costs at urgent care centers. Medicare supplements Original Medicare by essentially filling in the gaps of what is not already covered. Medicare supplement insurance is provided by private insurance companies

However, it is important to note that the following are not covered by a Medicare supplement: 

• Prescription drugs

• Vision, dental, and hearing care

Do note, a Medicare supplement plan is not the same as a Medicare Advantage plan. 

Most urgent cares accept Medicare, and in most cases, Medicare covers urgent medical services. What is not covered under Original Medicare are prescription drugs. However, under a separate Medicare plan, known as Part D, Medicare beneficiaries can receive prescription drug coverage. This is also true under a Medicare Advantage Plan.

During the COVID-19 pandemic, senior Americans may be hesitant to visit medical facilities due to the risk of exposure. One way to go around this issue is by scheduling virtual visits.

Medicare Part B will typically pay for certain telehealth services. Under Medicare Part B, patients pay 20% of the Medicare-approved cost for the given healthcare provider. The Medicare Part B deductible still applies as well. Usually, the amount owed for a virtual visit will match what would be charged were the services supplied in person.

To know the overall cost for a telehealth visit, a Medicare beneficiary should confirm their coverage with a given provider prior.

Note: Learn about the COVID-19 vaccine for older adults at this resource.

Medicare patients should bring the following items to urgent care:

• Insurance cards

• Identification

• Form of payment 

• Mask

• List of current medications

As well, before Medicare beneficiaries go to urgent care, they should ensure that the urgent care location accepts Medicare. While many urgent care centers take Medicare insurance, knowing financial obligations ahead of time is helpful. 

Medicare patients can discuss the services covered by Medicare with a licensed insurance agent, licensed insurance agency, or their insurance company to fully understand their financial obligations. 

While Medicare urgent care coverage will vary, Medicare plans, including most Medicare Advantage plans, covers urgent care. As well, most urgent care centers accept Medicare.

Can Medicare patients go anywhere for care?

Patients on Medicare can visit any doctor or hospital that takes Medicare in the United States.

What is an emergency medical condition as defined by Medicare?

An illness, injury, or condition that warrants immediate medical attention in order to avoid serious harm to one's health. Common emergency medical conditions include but are not limited to allergic reactions, broken limbs, bleeding that won't stop, issues with breathing, and more.