Medicare and Emergency and Urgently Needed Care

You never know when an emergency will arise, but you can be prepared. Learn the difference between an emergency medical condition and an urgently needed care situation. Medicare covers emergency ambulance services. (In limited cases, it covers non-emergency in 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.

Please 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 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.

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. 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.

Please call Lynn Hixon, state health insurance assistance program (SHIP) coordinator at the DeKalb County Council on Aging, at 256-845-8590 if you have any questions.