Emergency and Urgently Needed Care

Emergency Care

All Medicare Advantage plans are required to use what is known as the "prudent layperson" standard in making coverage decisions about emergency care. Under this standard, if you have acute symptoms, such as severe pain, an injury, sudden illness, or suddenly worsening illness that would cause a reasonably prudent layperson to expect that delay in treatment may cause serious danger to your health if you do not get immediate medical care. Your plan is required to provide access to emergency care services 24 hours a day, 7 days a week.

Your plan must pay for emergency care you receive from any provider. You can receive emergency care, the doctor or hospital that provides the service will bill either you or your plan. Following a medical emergency, your plan must also pay for care you need before your condition is stable enough for you to return to your plan's provider. If your condition lets you return to the plan service area, you will need to get follow-up care from your Medicare Advantage plan.

It is recommended that you try to reach your primary care physician if at all possible. You should contact the plan within 24 hours or as soon as possible after the emergency occurs outside the service area. If what you believed was an emergency turns out not to be, the plan must still pay. Your plan can require that you pay the entire cost of care received in an emergency room for a problem that you knew was not an emergency. You can appeal a denial of payment for emergency services.

Urgent Care

Urgent care is also required to be covered by a Medicare Advantage plan. An urgent care situation would include an accident or sudden illness while you are away from home. If you are a frequent traveler, you should inquire about the plan's guidelines for services when you are out of its geographic service area, including refills on prescription drugs and access to non-urgent or emergency medical services. Your Medicare Advantage plan may have a passport plan* provision allowing you to see providers in other parts of the country, if the plan provides this benefit. Under a Private Fee For Service plan (PFFS) your coverage is not limited by geographic service area. If you need medical attention, you may go to any doctor, specialist, or hospital that is approved for Medicare and accepts the plan's payment terms.

*Passport Plan: A passport plan provision is defined as a network of providers who are outside of your plan's service area, usually in a different state, which can be used by you in non-emergency or urgent care. Plans have these networks available to individuals who travel to certain states. Check with your plan on the availability of this provision.