does hospice pay for emergency room visits

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Understanding Hospice Eligibility and Its Impact on Emergency Department Visits

Dr. Andrew Mayo

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Patients with late-stage illnesses who frequently visit the Emergency Department often face unpredictable medical needs. These individuals typically have advanced, chronic, or progressive diseases such as cancer, heart failure, COPD, along with advanced neurological conditions. Their visits to the Emergency Department are often caused by uncontrolled symptoms, complications, or sudden emergencies related to their end-of-life illness.

Addressing the needs of these patients requires an approach that focuses on proactive symptom management, improved care coordination, and enhancing access to appropriate supportive services, with the goal of reducing Emergency Department visits while providing exceptional end-of-life care for these individuals in the late stages of their illnesses.

How Hospice Impacts Positively and Reduces Frequent Emergency Department Visits

Hospice care plays a significant role in positively impacting and reducing frequent Emergency Department visits for patients with late-stage illnesses. Here are some ways hospice achieves this:

• Proactive Symptom Management: Hospice care prioritizes effective symptom management to keep patients as comfortable as possible. By providing comprehensive pain control, managing symptoms, and offering emotional support, hospice helps prevent events that may lead to emergency department visits.
• Enhanced Care Coordination: Hospice care prioritizes effective symptom management to keep patients as comfortable as possible. By providing comprehensive pain control, managing symptoms, and offering emotional support, hospice helps prevent events that may lead to emergency department visits.
• 24/7 Support and Education: Hospice care provides 24/7 support and education for patients and their families. This availability helps address concerns and manage symptoms promptly, providing reassurance and reducing the need for emergency department visits. Families are educated with skills that are necessary to handle medical crises at home while helping them make decisions about when to seek urgent care.
• Focus on Comfort and Care: Hospice care focuses on improving the quality of life and ensuring a peaceful end-of-life experience. By prioritizing comfort and care, hospice reduces the physical and emotional distress that may drive patients to the emergency room. The quality end-of-life care focuses on the patient’s overall well-being, resulting in a decrease in unnecessary emergency department visits.

The Benefits of Early Hospice Enrollment

Enrolling in hospice care early can have a significant impact on reducing Emergency Department visits and preventing hospital readmissions for patients nearing the end of life. By joining hospice care at an earlier stage, patients benefit from comprehensive support, symptom management, care coordination, and advance care planning. The St. Croix Hospice team focuses on managing symptoms, ensuring better control and reducing the need for Emergency Department visits. Early enrollment also promotes discussions about advance care planning, allowing proactive crisis management and honoring the patient’s preferences.

Criteria for Hospice Care

To qualify for hospice care, several criteria must be met, including a specific life expectancy. The hospice physician must verify, with supporting documentation, that the patient’s terminal illness is expected to run its normal course and result in a prognosis of six months or less.

Additionally, the patient’s primary physician, if they have one, must also concur with this prognosis. When a discussion has been had and the patient no longer has curative options, or when the side effects of treatment outweigh the benefits, hospice is ultimately the appropriate choice.

Finally, the patient or their representative must sign admission paperwork, formally selecting hospice care as the preferred approach for addressing the terminal illness and any related conditions. These criteria ensure that hospice care is provided to individuals who have a limited life expectancy and have chosen a comfort-oriented approach to their care.

Encouraging Emergency Department Staff and Caregivers to Consider Hospice Care

Hospice care enhances the quality of life for patients with life-limiting illnesses. By identifying eligible patients, they receive comprehensive care, addressing pain, symptoms, emotional, and spiritual needs. It promotes comfort, dignity and overall well-being during the end-of-life journey. Identifying hospice-eligible patients facilitates timely intervention and patient-centered decision-making. It empowers patients to actively participate in their care and supports their families. By recognizing patients who may benefit from hospice, healthcare providers optimize resource allocation, ensuring appropriate and timely care while reducing unnecessary interventions.

How St. Croix Hospice Can Help a Patient and a First Responder

St. Croix Hospice can assist patients and their families by offering personalized care plans, pain management, emotional support and education on end-of-life care. Additionally, we can collaborate with first responders by providing them with the necessary information and resources, ensuring they are equipped to handle situations involving hospice patients effectively. It can also benefit first responders by reducing their burden of responding to emergency calls related to end-of-life care, allowing them to focus on other critical emergencies in the community.

Services provided by St. Croix Hospice include:

• 24/7 Availability
• Same-Day Admission
• On-site or Telehealth Consults

St. Croix Hospice Referral Process

The referral process for St. Croix Hospice is simple and straightforward. A referral can be made by anyone, including a patient, family member, friend, or healthcare professional. To start the referral process, you can:

• Call our toll-free number: (877) 855-1393
• Visit our Refer a Patien t page
• Consult with your healthcare provider

Once the referral has been received, St. Croix Hospice will contact the patient and their family to discuss their care needs and preferences, assess eligibility and determine the most appropriate plan of care. By offering a comprehensive range of services and a seamless referral process, St. Croix Hospice provides exceptional end-of-life care to patients and their families.

Frequently Asked Questions

What is the role of emergency room admission in hospice care?

The role of emergency room admission in hospice care is to address acute medical emergencies and provide immediate evaluation and management of distressing symptoms. It allows for collaboration between healthcare professionals, facilitates crisis intervention, and ensures appropriate care for hospice patients.

Can hospice care providers offer medical treatment at home?

Yes, hospice care providers can offer medical treatment at home. Hospice care is often provided in the patient’s home, and the interdisciplinary hospice team, including doctors and nurses, can administer medical treatments, manage symptoms, and provide necessary care and support in the comfort of the patient’s own residence.

What types of medical equipment are available for use in hospice care?

Medical equipment commonly used in hospice care includes items such as hospital beds, mobility aids (such as wheelchairs or walkers), oxygen therapy equipment, specialized mattresses for pressure ulcer prevention, medication administration devices (like infusion pumps), and equipment for pain management (such as PCA pumps for self-administered pain relief). The specific equipment provided depends on the patient’s needs and the services offered by the hospice care provider.

How does hospice care ensure that patients receive timely and appropriate care in the event of an emergency?

Hospice care ensures that patients receive timely and appropriate care in the event of an emergency by providing 24/7 availability of on-call hospice staff who can promptly respond to emergencies. These staff members are trained to address urgent situations, provide guidance to patients and their families, coordinate with emergency medical services, and facilitate the necessary interventions to alleviate distress and ensure the patient’s comfort and well-being.

Can hospice care providers communicate with a patient’s primary care physician or specialist to coordinate care and avoid unnecessary emergency room visits?

Yes, hospice care providers can and often do communicate with a patient’s primary care physician or specialist to coordinate care and avoid unnecessary emergency room visits. Collaborative communication between healthcare providers ensures that the patient’s overall care plan is aligned, allowing for proactive symptom management, timely interventions, and appropriate adjustments to the care plan based on the patient’s needs and preferences.

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FAQ: What services are typically covered by hospice benefits?

Most people receive hospice care through the Medicare Hospice Benefit. Medicaid and the Veteran’s Health Administration follow the Medicare benefit model.

The services that the Medicare Hospice Benefit covers are:

• Doctor services
• Nursing Care
• Medical equipment (such as hospital beds, wheelchairs or walkers)
• Medical supplies (such as bandages and catheters)
• Drugs to control pain and other symptoms
• Home health aide and homemaker services
• Physical and occupational therapy
• Speech therapy (to help with problems such as swallowing)
• Social worker services
• Dietary counseling
• Emotional and spiritual counseling to help the patient and family with grief and loss
• Short-term in-patient care in the hospital, including “respite care”, which is a service designed to provide family members a short break from caring for their loved one at home

Keep two things clearly in mind:

The services provided depend on what the patient and the family need. Which services a patient receives and how often services are received are based on the needs of each patient and family. The services that are provided can be adjusted as the situation of the patient and family change over time. When patients decide to receive hospice care, the hospice talks with them about what their personalized care involves.

Some hospices provide additional services beyond those covered by the Medicare Hospice Benefit or other insurance. Examples are special types of chemotherapy and radiation that do not cure a disease, but help to ease symptoms (this is called “palliative” chemotherapy and radiation). If there is a service that you think you or your family member needs, ask your hospice nurse or doctor about getting it.

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Overview of Medicare Hospice Benefits

Medicare's hospice benefit pays for hospice care for people with Medicare. If you or a loved one have Medicare and are considering enrolling in hospice care, this article will explain what you need to know about how Medicare covers hospice care.

To be eligible for hospice coverage, you must have a life expectancy of fewer than six months. But if you live longer than six months, you can continue to receive hospice benefits as long as your hospice doctor recertifies that you're terminally ill. The recertification is initially after 90 days and 180 days, and then every 60 days thereafter.

Additionally, you must agree to forgo further curative treatment options for your terminal illness, instead choosing treatment options aimed at keeping you comfortable and maintaining as good a quality of life as possible. But if you decide that you do want to receive treatment for the terminal illness, you can choose to end your hospice coverage and return to regular Medicare coverage at any time.

If you have Medicare and choose a Medicare-certified hospice organization to provide your hospice care, nearly all of your costs will be covered.

What the Medicare Hospice Benefit Covers

The Medicare hospice benefit covers all of the care related to your terminal illness and necessary to keep you comfortable, as long as you receive your care from a Medicare-approved hospice vendor. It pays for:

• Hospice physicians and nurses.
• Medications necessary to keep you comfortable and control or prevent your symptoms.
• Hospice home health aides to help with bathing and bed changes.
• Medical equipment like a wheelchair or hospital bed necessary to keep you comfortable.
• Social workers to help you get your affairs in order and to help you and your family deal with emotional difficulties and grief.
• Respite care needed to give your caregiver a break. This will be in an inpatient facility, for up to five days at a time, on an occasional basis.
• Speech, occupational, or physical therapy needed to keep you comfortable or teach you how to cope with the changes your body is undergoing.
• Dietician services if necessary.
• Grief counseling for both you and your loved ones.
• Inpatient admission if necessary for crisis management, approved by the hospice team, and received at a hospital or hospice facility contracted with your hospice organization.
• Anything else the hospice team feels is necessary and related to keeping you comfortable and limiting the symptoms of your terminal illness.

What It Doesn't Cover

The Medicare hospice benefit doesn’t cover anything aimed at curing your terminal illness. For example, it might cover the cost of radiation therapy aimed at shrinking a tumor that is pressing against your spinal cord causing pain.

However, it wouldn’t cover radiation therapy aimed at curing your disease. The key is whether the treatment is to control your symptoms so you can be comfortable (covered), or whether the treatment is an attempt to cure your terminal illness (not covered). But again, you can choose to end hospice care at any point and switch back to regular Medicare if you decide you want to focus on curative treatments.

The Medicare hospice benefit also doesn’t cover the cost of room and board with the exception of short-term inpatient stays arranged by the hospice team or respite care of up to five days at a time. This isn’t usually a problem if you’re in your own home, which is where hospice care is generally provided.

But if you are in a nursing home, assisted living facility, board and care home, or living at a hospice facility, you’ll be responsible for covering your room and board costs.

If it’s clear that you need to live in a nursing home, assisted living, or hospice house but can’t afford room and board, some hospice organizations will use charitable donations to assist you with those costs.

This is usually done on a case-by-case basis, so if you predict this may be an issue, ask about it as you’re choosing which hospice organization to use. Depending on your financial situation, you may also find that Medicaid might cover the room and board costs associated with a nursing home .

Emergency room and ambulance services aren’t covered by Medicare hospice benefit unless your hospice team feels they’re necessary and arranges for you to receive those services, or unless they're unrelated to your terminal illness (for example, you're in hospice due to a terminal cancer diagnosis, but then you fall and break your leg and need to be transported to the emergency room for treatment that has nothing to do with your cancer).

What You'll Have to Pay

You will have a small copay of $5 for medications, although some hospice organizations waive this copay. You may have a 5% coinsurance for the cost of any respite care (meaning you pay 5% of the Medicare-approved cost).

If you have a Medigap plan , it will cover some or all of your out-of-pocket costs for hospice. The specifics will depend on what Medigap plan you have, as each plan (standardized with letter names) provides different benefits.

You will pay the Medicare Part B deductible and coinsurance for any physician services you receive from a doctor who isn’t working for your hospice organization.

And if you receive inpatient hospital care that's unrelated to your terminal condition, you'll be responsible for the normal Part A deductible (if you have a Medicare Advantage plan and choose to keep it, you'll pay your plan's normal cost-sharing if and when you need inpatient or outpatient care that's unrelated to your terminal condition and thus not covered by your hospice benefit).

You'll need to continue paying any Medicare premiums you were paying before you signed up for hospice. This includes the Medicare Part B premium, as well as a premium for Part D and/or a Medigap policy or Medicare Advantage plan, if you have any of those plans.

How the Medicare Hospice Benefit Works

The Medicare hospice benefit is part of Medicare Part A . When you sign up for hospice, whether you’re on Original Medicare or a Medicare Advantage Plan like a Medicare HMO, you’ll automatically (in most cases) be covered under the Original Medicare hospice benefit. (There are some exceptions, under a pilot program described below.)

If you're enrolled in a Medicare Advantage plan and you need hospice care, you can choose to remain in that plan as long as you continue to pay the premium, and the Medicare Advantage plan will continue to cover your healthcare needs that are not related to your hospice needs or your terminal condition. Or you can choose to get care that's unrelated to your terminal illness via Original Medicare, with the regular deductibles and coinsurance that apply to that coverage.

However, the Centers for Medicare and Medicaid Services rolled out a pilot program, starting in 2021, that allows Medicare Advantage plans to incorporate a hospice benefit. For insurers that participate, the program allows Medicare Advantage beneficiaries to receive hospice care via their existing insurance plan, with the same coordination of care that they receive for other services.

The Medicare Advantage hospice benefit pilot program is part of the Value-Based Insurance Design (VBID) model. As of 2024, there are 13 Medicare Advantage organizations participating in the hospice benefit pilot program, with coverage available in 19 states (down from 15 organizations that provided plans in 23 states in 2023).

Enrollees in these plans receive hospice benefits through the Medicare Advantage plan, rather than Original Medicare. But in most cases, if you're enrolled in Medicare and you need hospice care, it will be provided by Original Medicare Part A, even if you're otherwise enrolled in a Medicare Advantage plan.

Medicare will pay the hospice organization a set dollar amount for every day you’re their patient. This set dollar-per-day rate is known as a per-diem rate.

The hospice organization pays for all of your necessary hospice care out of its per-diem rate. It gets this money every day whether or not the hospice nurse or home health aide comes to visit you that day.

The hospice organization now acts a bit like an HMO in that you’re only allowed to get healthcare services related to your terminal illness from that hospice organization , or from another healthcare provider it contracts with.

For example, if you need home oxygen and a hospital bed, you can’t get them from any medical equipment provider you choose. Instead, you must get them from the medical equipment provider your hospice organization contracts with, and your hospice must agree that you need these items.

You may still get healthcare services that aren’t related to your terminal illness from non-hospice providers. For example, if your terminal illness is cancer, you may continue to see your cardiologist for treatment of your heart arrhythmia since it has nothing to do with your terminal illness.

Hospice won’t pay for the cardiologist out of its per-diem since that doctor’s visit wasn’t related to your terminal illness. However, Original Medicare Part B will pay for the cardiologist visit as it has in the past (or, if you have a Medicare Advantage plan that you've kept in place, it will cover the cardiologist visit under the plan's normal terms).

In another example, if your terminal illness is pulmonary hypertension and you need to be hospitalized because you tripped and broke your hip, Original Medicare Part A would pay for your hip-related hospitalization, and Original Medicare Part B would pay the doctor bills associated with your hip—or your Medicare Advantage plan would cover the treatment for your hip if you have an Advantage plan and choose to keep it after electing Medicare's hospice benefit.

So Medicare will cover the costs of palliative care for your terminal illness (with the Medicare hospice benefit) as well as healthcare costs unrelated to your terminal illness (with Medicare Parts A and B, or your Medicare Advantage plan), subject to the normal cost-sharing requirements for the services you need.

What Happens If You Change Your Mind

If you change your mind about hospice after you’ve signed up, you may revoke the Medicare hospice coverage and continue to receive care under Original Medicare, or a Medicare Advantage plan if you're enrolled in one.

If you want to continue to receive hospice services, but change your mind about the hospice organization you’ve chosen, you may switch to a different hospice organization. However, you can’t switch hospice organizations any time you wish. You may switch one time during the first 90 days of your care, one time during the second 90 days of your care, and once every 60 days thereafter. Hopefully, you’ll be able to find a hospice organization you’ll be happy with and not need to change.

Medicare has a robust hospice benefit. It is available to any beneficiary who is diagnosed with a terminal illness, as long as a doctor certifies that they're expected to live less than six months. In most cases, the hospice benefit is provided via Original Medicare (Part A), even for beneficiaries who are enrolled in Medicare Advantage plans. But a pilot program began in 2021 that allows some Medicare Advantage plans to provide hospice benefits directly to their enrollees.

A Word From Verywell

If you or a loved one with Medicare is in need of hospice care, rest assured that the program provides strong hospice benefits. Your costs will be minimal, and all necessary palliative care will be covered. If treatment is needed for a condition unrelated to the terminal illness, Medicare will continue to provide those benefits just like normal, in addition to the hospice care. The Medicare hospice benefit also includes inpatient respite care, so that your normal caregiver can have a chance to rest.

Centers for Medicare and Medicaid Services. Medicare Hospice Benefits .

Centers for Medicare and Medicaid Services. Medicare Learning Network. Hospice Payment System . January 2019.

Medicare.gov. How to Compare Medigap Policies. Compare Medigap Plans Side-by-Side .

Centers for Medicare and Medicaid Services. Newsroom. Medicare Advantage Value-Based Insurance Design Model Calendar Year 2021 Fact Sheet . December 19, 2019.

Centers for Medicare and Medicaid Services. VBID Model Hospice Benefit Component Participating Plans, 2024 .

Parker, Jim. Hospice News. Health Plan Participation in Hospice VBID to Shrink in 2024 . September 27, 2023.

By Elizabeth Davis, RN Elizabeth Davis, RN, is a health insurance expert and patient liaison. She's held board certifications in emergency nursing and infusion nursing.

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Who Pays for Hospice? An Overview of Hospice Care Cost and Payment Options

End-of-life care is a deeply personal and vital journey for older adults, aiming to alleviate physical discomfort, uplift their overall well-being and offer emotional solace to both them and their families. This kind of care also provides families the precious opportunity to be present emotionally, rather than being overwhelmed by the day-to-day practicalities of caregiving. Yet, it’s important to acknowledge that this stage, despite its many benefits, often evokes  deep emotions and reflections for seniors and their loved ones. 

This guide aims to alleviate concerns about financing hospice care by providing a comprehensive overview of payment options. It explores solutions such as Medicaid, Medicare and insurance, considering eligibility for each.

• What Is Hospice? 

Hospice is a unique type of care for those with life-limiting conditions who are nearing the end of their lives. Person-centered hospice care revolves around making an individual more comfortable, managing symptoms and maintaining as high a quality of life as possible. 

Care plans are tailored to each individual’s condition and wishes, and services are designed to support family members as well as the primary care receiver. Typical  hospice services include pain management and medication administration, personal care, assistance with daily activities and emotional support. 

Hospice is a suitable care option for those who have a terminal diagnosis and are expected to live fewer than six months.  Physicians must certify that hospice care is appropriate before an individual begins specialized care. 

How Much Does Hospice Care Cost? 

The exact cost of hospice care depends on factors such as the number of care hours needed, the precise services required, the care setting and the location. However, end-of-life care is typically more affordable than other types of senior care.

As an estimate, hospice care averages from $150 per day for care at home to $650 for care in a specialized inpatient facility.  

Where Is Hospice Care Provided? 

Seniors can choose to receive hospice care in one of several settings . While many individuals prefer to live the final stage of their lives at home , some also choose to stay in a residential hospice facility. Care environments include:

• Hospital   
• Hospice Facility  
• Nursing Home
• Assisted Living Facility 

Hospice Care vs. Palliative Care 

Although they provide similar services, there are distinct differences between hospice care and palliative care. Both provide comfort, symptom relief and pain management for people with serious conditions. Differences include:

• Stage of Illness : Hospice care is for terminally ill individuals who have received a prognosis of six months or less. Palliative care can be used to provide relief at any stage of disease progression.
• Intent of Care and Treatment : Hospice care is designed to provide comfort and care toward the end of life; it doesn’t include any curative or experimental treatments. Palliative care can be used alongside techniques and medications with the hope of curing an illness or delaying disease progression. 
• Does Medicaid Pay for Hospice? 

While  hospice coverage is an optional benefit within Medicaid, most states choose to provide this essential care for qualifying seniors. Medicaid, a federal health insurance program, offers health care coverage to individuals across all age groups who meet specific criteria.

In addition to standard Medicaid designed for low-income individuals, there are programs specifically tailored to support those in need of nursing home care as well as the elderly, blind, or disabled. Additionally, many states have instituted various  waiver programs to further support their residents. 

Medicaid Coverage of Hospice Services 

Medicaid will generally pay for  wide-ranging services , including home and nursing care, counseling, facility room and board and doctor services . This comprehensive coverage ensures that beneficiaries can access essential care without facing overwhelming financial burdens. 

Eligibility for Medicaid Coverage of Hospice Care

For Medicaid to cover hospice care, most states require:

• An individual to sign, saying they choose hospice care rather than regular Medicaid benefits.
• A doctor to certify that the individual has a life-limiting condition and may not live over six months.

Seniors can learn more at Medicaid.gov , via their state’s Medicaid program or from their local Area Agency on Aging or Aging and Disability Resource Center .

• Does Medicare Pay for Hospice? 

Yes, Medicare Part A may cover hospice care for qualifying individuals. Medicare is the federal health insurance program designed primarily for people aged 65 and older, as well as individuals with disabilities. It comprises several main components: A, B, and D. Generally, those enrolled in Medicare have accumulated sufficient credits from their own (or their spouse’s) payroll taxes during their working years.

Medicare Coverage of Hospice Services 

Under Part A, Medicare covers an extensive range of hospice care services , whether provided at home—including in assisted living and skilled nursing facilities—or in a Medicare-approved hospice facility.

Some services include prescriptions drugs, spiritual support, nursing care and medical supplies and equipment. However, it seldom covers bed and board costs of inpatient settings. It’s important to note that there are duration limits on how long individuals can receive hospice care.

Eligibility for Medicare Coverage of Hospice Care

To qualify for hospice care through Medicare , seniors must already be enrolled in Medicare Part A. Other eligibility criteria include:

• Physician certification that an individual has a terminal diagnosis and is not expected to live more than six months.
• The individual’s signature to accept hospice care rather than other Medicare-covered treatments.
• The individual’s agreement to receive hospice care rather than curative solutions.

Further information can be obtained from Medicare.gov or from an individual’s Medigap provider.

• Veterans Benefits for Hospice Care 

Both Veterans Affairs (VA) and TRICARE benefits cover hospice care for qualifying individuals. This ensures that veterans and military service members, as well as their families, receive the compassionate end-of-life care they deserve. 

VA benefits allow people to receive hospice care at home, in a residential setting or at an outpatient clinic. Covered services include symptom control, medication management, emotional support and grief counseling.

TRICARE benefits are available for people receiving hospice care at home or in a certified facility. They only cover the cost of room and board for seniors in an inpatient facility or who are obtaining respite care. Benefits typically cover home health aide services, comfort care and emotional support.

Eligibility for TRICARE or VA Coverage of Hospice Care

Because hospice care is included in the VHA Standard Medical Benefits Package, all enrolled veterans qualify for hospice care if they fulfill the medical need criteria of having a terminal diagnosis and a life expectation of no more than six months.

To qualify for TRICARE coverage for hospice care, a doctor must order such care and the recipient must sign a statement indicating that they choose hospice care over other treatments.

• Does Private Insurance Cover Hospice Care? 

Most private health insurance policies cover end-of-life care. Plans often cover all costs associated with hospice care for those who meet certain requirements. Seniors should contact their brokers to find out what their private policies cover.

Individuals may also sign up for various forms of long-term care insurance. Hospice care  isn’t considered a type of long-term care . However, some policies may include limited hospice provisions. Individuals should contact their providers to find out what exactly is covered.

• Other Ways to Pay for Hospice Care

Although many seniors qualify for funding for hospice care, the above options may not apply to some individuals. In such cases, seniors must source their care costs from other places. Options include private pay, whereby they use savings or income to pay for care, financial help from family members and charitable assistance.

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Who covers an ER visit if a patient was on hospice?

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Hospice patients don’t need to revoke medicare hospice benefit if they visit ed.

The 78-year-old gentleman you are treating again for episodes of acute heart failure tells you he was recently admitted to hospice. If the patient needs hospitalization, you ask your staff, how is this handled?

They tell you all hospice patients seen in the ED must revoke their hospice benefit. This troubles you. Whether or not your patient is hospitalized, he will need to be re-admitted to hospice to get follow-up care at home.

Although this happens all the time, there is a better way: A hospice patient receiving symptom management in the ED does not need to revoke, something you as his physician can help him understand.

The Medicare Hospice Benefit  belongs to the patient, who voluntarily signs up for hospice with the understanding that he will receive palliative care in lieu of curative care for his terminal illness. The patient must revoke the benefit if he decides to receive curative care.

However, symptom management, like the care received in the ED for an episode of acute heart failure, is not considered curative care. It is covered under the Medicare Hospice Benefit , as is ambulance delivery and even hospital admission into a contracted hospice bed. The hospice may not be aware that their patient is in the ED for care management, but once informed, the hospice must pay for any palliative services that address the terminal diagnosis.

Hospices contract with hospitals for general inpatient beds or hospice units. Under Medicare policy, admission to such a bed is not a readmission; it is considered a transitional bed to manage acute symptoms and improve ED throughput—and it is paid for by the hospice. Only when there is no contractual agreement or when the patient revokes his hospice benefit is the care billed to the patient or the patient’s insurer. Revocations are not retroactive; any care provided prior to revocation is paid by the hospice.

Your ED patient should not revoke his benefit. Ideally, he will stay on hospice service and be returned home without being admitted, or be admitted to a GIP bed or inpatient hospice unit if the hospice has such an agreement.

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For a one-stop resource focused on the informational needs and interests of Medicare Fee-for-Service (FFS) hospices, visit the Hospice Center webpage

Hospice Coverage

Hospice is a comprehensive, holistic program of care and support for terminally ill patients and their families. Hospice care changes the focus to comfort care (palliative care) for pain relief and symptom management instead of care to cure the patient’s illness.

Patients with Medicare Part A can get hospice care benefits if they meet the following criteria:

• They get care from a Medicare-certified hospice
• Their attending physician (if they have one) and the hospice physician certifies them as terminally ill, with a medical prognosis of 6 months or less to live if the illness runs its normal course
• They sign an election statement to elect the hospice benefit and waive all rights to Medicare payments for the terminal illness and related conditions

After certification, the patient may elect the hospice benefit for:

• Two 90-day periods followed by an unlimited number of subsequent 60-day periods.
• After the second, 90-day period, the recertification associated with a hospice patient’s third benefit period, and every subsequent recertification, must include documentation that a hospice physician or a hospice nurse practitioner had a face-to-face (FTF) encounter with the patient. The FTF encounter must document the clinical findings supporting a life expectancy of 6 months or less.

All hospice care and services offered to patients and their families must follow an individualized written plan of care (POC) that meets the patient’s needs. The hospice interdisciplinary group establishes the POC together with the attending physician (if any), the patient or representative, and the primary caregiver.  

Items & Services Included in the Hospice Benefit 

The Medicare hospice benefit includes these items and services to reduce pain or disease severity and manage the terminal illness and related conditions:

• Services from a hospice-employed physician, nurse practitioner (NP), or other physicians chosen by the patient
• Nursing care
• Medical equipment
• Medical supplies
• Drugs to manage pain and symptoms
• Hospice aide and homemaker services
• Physical therapy
• Occupational therapy
• Speech-language pathology services
• Medical social services
• Dietary counseling
• Spiritual counseling
• Individual and family or just family grief and loss counseling before and after the patient’s death
• Short-term inpatient pain control and symptom management and respite care

Medicare may pay for other reasonable and necessary hospice services in the patient’s POC. The hospice program must offer and arrange these services  

Hospice Levels of Care

Generally, Medicare pays hospice agencies a daily rate for each day a patient is enrolled in the hospice benefit. Medicare makes this daily payment regardless of the number of services provided on a given day, including days when the hospice provides no services. The daily payment rates cover the hospice’s costs for providing services included in patient care plans. Medicare makes daily payments based on 1 of 4 levels of hospice care:

• Routine home care : A day the patient elects to get hospice care at home and isn’t getting continuous home care. A patient’s home might be a home, a skilled nursing facility (SNF), or an assisted living facility. Routine home care is the level of care provided when the patient isn’t in crisis. 
• The patient gets hospice care in a home setting that isn’t an inpatient facility (hospital, SNF, or hospice inpatient unit)
• The care consists mainly of nursing care on a continuous basis at home  Patients can also get hospice aide, homemaker services, or both on a continuous basis. Hospice patients can get continuous home care only during brief periods of crisis and only as needed to maintain the patient at home.  
• Inpatient respite care : A day the patient elects to get hospice care in an approved inpatient facility for up to 5 consecutive days to give their caregiver a rest.
• General inpatient care : A day the patient elects hospice care in an inpatient facility for pain control or acute or chronic symptom management, which can’t be managed in other settings.

Hospice Coinsurance

Hospices may charge patients for these coinsurance amounts: 

• The patient owes a coinsurance payment when they got it during routine home care or continuous home care. The coinsurance amount is 5% of the cost of the drug or biological to the hospice, determined by the drug copayment schedule set by the hospice. The coinsurance for each prescription may not be more than $5.00. 
• The patient does not owe any coinsurance when they got it during general inpatient care or respite care.
• Respite Care Coinsurance: The patient’s daily coinsurance amount is 5% of the Medicare payment for a respite care day. The coinsurance amount may not be more than the inpatient hospital deductible for the year that the hospice coinsurance period began. This level of care includes room and board costs. 

Hospice Quality Reporting Program 

For more information about quality data submission and reporting requirements, visit the Current Measures and Hospice Quality Reporting webpages.

Hospice Information for Medicare Part D (ZIP)

Instruction and Form for Hospice and Medicare Part D (PDF)

Model Hospice Election Statement Addendum - March 2024 (PDF)

Model Example of Hospice Election Statement - March 2024 (PDF)

Ejemplo modelo de la Declaración de elección de hospicio - Junio 2020 (PDF)

Modelo de Referencia de "Aviso al Paciente sobre Artículos, Servicios y Medicamentos de Hospicio No Cubiertos" - Julio 2021 (PDF)

Related Links

• Hospice Request for Certification in the Medicare Program - Form CMS-417
• Advance Beneficiary Notice of Non-Coverage - Form CMS-R-131 (ZIP)
• Hospice Care Regulation: Title 42, Chapter IV, Part 418
• Title 18, Section 1861 of the Social Security Act (Subsection dd)
• Medicare Benefit Policy Manual - Chapter 9 - Coverage of Hospice Services Under Hospice Insurance (PDF)
• Medicare Claims Processing Manual - Chapter 11 - Processing Hospice Claims (PDF)

What is Hospice?

Hospice is:.

• Medical care for people with an anticipated life expectancy of 6 months or less, when cure isn’t an option, and the focus shifts to symptom management and quality of life. 
• An interdisciplinary team of professionals trained to address physical, psychosocial, and spiritual needs of the person; the team also supports family members and other intimate unpaid caregivers.  
• Specialty care that is person-centered, stressing coordination of care, clarification of goals of care, and communication.
• Provided primarily where a person lives, whether that is a private residence, nursing home, or community living arrangement, allowing the patient to be with important objects, memories, and family.
• Care that includes periodic visits to the patient and family caregivers by hospice team members. Hospice providers are available 24 hours a day, 7 days a week to respond if patient or caregiver concerns arise.
• The only medical care that includes bereavement care, which is available during the illness and for more than a year after the death for the family/intimate network.
• A Medicare benefit; to which all Medicare enrollees have a right. Hospice care also is covered by most private health insurance at varying levels, and in almost every state, by Medicaid. Read more about paying for hospice .

Hospice is not:  

• Focused on curative therapies or medical intervention designed to prolong life.
• A replacement for nursing home care or other residential care.
• 24/7 care, in the majority of cases.
• Care that hastens death.

Who is eligible to receive hospice care?

• Adults with a terminal illness and lifetime prognosis of 6 months or less are eligible for hospice care.
• Hospice care is also available for children and adolescents. Rules and regulations regarding hospice services and coverage for children are different from those utilized in the adult population.
• Common diagnoses of those who receive hospice care include, but are not limited to: cancer, heart disease, dementia, Parkinson’s disease, lung disease, stroke, chronic kidney disease, cirrhosis, and Lou Gehrig’s disease (ALS).   

When is it time for hospice?

• There is a significant decline in physical and/or cognitive status despite medical treatment. This may include increased pain or other symptoms, substantial weight loss, extreme fatigue, shortness of breath, or weakness.
• The goal is to live more comfortably and forego the often physically debilitating treatments that have been unsuccessful in curing or halting a life-threatening illness.
• Life expectancy is 6 months or less, according to physicians.
• The person is in the end stage of Alzheimer’s or dementia.​  

To qualify for hospice services:  

• A hospice physician and a second physician (often the individual’s attending physician or specialist) must certify that the patient meets specific medical eligibility criteria indicating that an individual’s life expectancy is 6 months or less if the illness or condition runs its typical course. These established criteria vary by illness and condition.
• Typically, referral to hospice care begins with the attending/specialist physician knowledgeable about the person’s medical history, and hospice eligibility is confirmed by the hospice physician.
• Self and family referral is possible (the person and/or family may contact hospice directly), but eligibility must be confirmed by physicians prior to receiving care.

What services does hospice provide?

• Time and services of the care team, including visits to the patient’s location by the hospice physician, nurse, medical social worker, home health aide , and chaplain/spiritual adviser
• Medication for symptom control, including pain relief
• Medical equipment like a hospital bed, wheelchairs or walkers, and medical supplies such as oxygen, bandages, and catheters
• Physical and occupational therapy*
• Speech-language pathology services*
• Dietary counseling*
• Any other Medicare-covered services needed to manage pain and other symptoms related to the terminal illness, as recommended by the hospice team
• Short-term inpatient care (e.g. when adequate pain and symptom management cannot be achieved in the home setting)
• Short-term respite care for family caregivers (e.g. temporary relief from caregiving to avoid or address “caregiver burnout”)
• Grief and loss counseling for the patient and loved ones, who may experience anticipatory grief. Grief counseling is provided to family members for up to 13 months after a death.

What's not included in hospice care?

• Treatment, including prescription drugs, intended to cure a terminal illness or other illness unrelated to the terminal diagnosis unless the other illness is causing increased symptom burden.
• Prescription drugs and supplies prescribed to treat an illness or condition unrelated to the diagnosis that qualifies the person for hospice.
• Room and board in a nursing home or hospice residential facility.
• Care in an emergency room, inpatient facility care or ambulance transportation, unless it is ordered by or arranged by the hospice team.

Where is hospice care provided?

• Hospice services are provided where a patient lives, which may be their private residence or that of a loved one, an assisted living center, nursing home, or in some cases, in a hospital.
• Some hospices have their own long-term residential centers where services are provided. When hospice care is provided at a residential center, the patient/family remains responsible for the costs associated with the residence, as they would for any other home.
• If a patient needs 24/7 care, hospices may transport the patient to a special inpatient facility for a short period of time to manage symptoms, with the goal of returning the patient to their home.

Who pays for hospice care?

• Most hospice patients are eligible for  Medicare , which covers all aspects of hospice care and services. There is no deductible for hospice services although there may be a very small co-payment for prescriptions and for respite care. In most states,  Medicaid  offers similar coverage.
• Many health insurance plans obtained privately, such as through an employer or on a state or the national exchange, offer a hospice benefit but the extent to which they cover hospice care and services may differ from Medicare as well as from one another.
• Military families have hospice coverage through  Tricare .
• The Veterans Health Administration offers hospice services and contracts with local community hospice providers. Any veteran with the VHA Standard Medical Benefits Package is eligible and there is no co-pay.
• Hospices accept private payment, referred to as “self-pay,” which may be an option for the uninsured.

What other requirements are important to know?

• Extensions : Hospice care is given in benefit periods: two 90‑day periods followed by an unlimited number of 60‑day periods. Although medical eligibility generally relies on the physician's opinion that the patient's life expectancy is 6 months or less, neither the patient nor the physician is penalized if the patient lives longer than 6 months. The patient can be re-certified for hospice care, provided medically eligibility is validated.
• Discharge : If a patient’s condition stabilizes or improves sufficiently, they may no longer meet medical eligibility for hospice services. At that time, the patient is “discharged” from the hospice program and their Medicare benefits revert to the coverage they had before electing hospice care.
• Revocation : Sometimes hospice patients may choose to pursue curative therapies such as entering a clinical study for a new medication or procedure. In order to do so, the patient must withdraw their selection of hospice care, called "revocation."

Hospice seems like the right decision? Here are some next steps:  

Learn about accessing hospice care. Learn about paying for hospice. Learn about choosing a hospice provider . Learn about preparing for hospice care.

​Is your loved one in a nursing home?

Click here to learn about receiving care in a nursing home.

Have a question about hospice care?

Click here to Ask a Hospice Expert.

Looking for information about filing a hospice care complaint?

Click here for information.

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Take the hospice knowledge quiz have a question ask an expert "it's been so helpful" karen jones, a young wife, mom and marathon runner living with advanced cancer shared her hospice experience on hfa's television special, "hospice - something more." x, community hospice options, chinese language resources spanish language resources, lgbt resources, idd resources - (mikesiddjourney.com), quality hospice care looking for a hospice provider here are suggestions for things to consider. x hospice: something more a rare glimpse into the lives of hospice patients. x.

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General Questions

Hospice is appropriate when the doctor believes that the remaining life span is measured in months instead of years and when the patient is ready to move from curative treatments to care that focuses on comfort and symptom relief. Diagnoses can include Heart Disease, Pulmonary/Lung Disease, Kidney Disease, Liver Disease, Stroke/Coma, Dementia/Alzheimer’s, ALS, Cancer or HIV. Pediatric diagnoses can include Heart Disease, Central Nervous System abnormalities, Chromosomal Abnormalities,  Respiratory Failure, Kidney or Liver Disease, Cancer and HIV.

This is one of the biggest myths of hospice care, one we struggle with all the time. Hospice care is much more effective, for both the patient and the family, if services are started sooner rather than later. The day a terminally ill patient and their family choose comfort care at home, over curative care in a hospital, Hoffmann Hospice will be there.

Anyone can make the first call; however, a physician must approve hospice care for the patient.

The decision to discontinue medications and treatments are made on a case-by-case basis and depend on patient need and stage of the disease.

No it’s not. Patients do not need to have a DNR order signed at the time of enrollment into a hospice program.

When a patient shows signs of recovery and receive an extended prognosis, they may be discharged from hospice services. At Hoffmann Hospice, the patient is captain of the ship and may revoke hospice services at any time to seek curative care.

Hospice is covered by Medicare and Medi-Cal, and most private insurances carry a hospice benefit. Hoffmann Hospice can assist you and your family in determining whether or not hospice services are covered. As a non-profit, Hoffmann Hospice provides care regardless of a patient’s ability to pay.

As an independent, community-based non-profit hospice, Hoffmann Hospice accepts eligible hospice patients, regardless of their ability to pay, based on the availability of funds donated by individuals, businesses and foundations in the community.

Not necessarily. Hospice patients may go to the emergency room to seek care for an injury or condition not related to their hospice diagnosis. For example, if a patient has a terminal diagnosis of cancer, but falls and breaks an arm, the patient may absolutely go to the ER for treatment of the broken arm. But if that same patient goes to the ER to seek treatment for the cancer, then, yes, the patient revokes hospice service. Remember, hospice care steps in when a cure is no longer realistic and the patient has decided they no longer wish to pursue curative measures.

We completely understand your concern, and we have recognized this need in families already served. Hoffmann Hospice has implemented a wonderful service called the Buddy Brigade. Hoffmann Hospice patients, who have children or siblings in the home, are immediately connected with a volunteer where they will have special time that they can call their own and engage in activities that they enjoy in the comfort of their home. These activities can range from playing a board game, outdoor activities or just hanging out watching TV. This program is offered through our Volunteer Department which includes specialized training and extensive background checks. Hoffmann Hospice’s goal has always been to support the entire family in addition to the patient.

No, it won’t. Hoffmann Hospice is committed to guiding our families through the end-of-life process, especially their grief, for up to 13 months after the death of their loved one. We keep in close touch with our families, contacting them monthly and providing one-on-one support when necessary. Our families also have access to Hoffmann’s well-stocked bereavement resource library and are invited to special events throughout year, including our holiday grief support luncheon, our Christmas ornament decorating party and, of course, our weekly support group meetings for adults and children. Our families are as important to us as our patients and it shows in our bereavement program.

Personalities and life experiences influence the way each of us deals with grief. Each person’s style of grieving must be respected so, in this sense, there is no right or wrong way to grieve. Generally, however, the amount of support a person receives can lessen the impact of grief and facilitate recovery. That is why we highly recommend our weekly grief support group meetings, which are open to the public.

Not at all. Hospice care teams go where our patients live – their private residence, skilled nursing facilities, residential care facilities, board and care homes, hotels or motels. We have even cared for a patient living in a motor home at the Kern County Fair. When you’re on service with Hoffmann, we’ll meet you wherever you call home.

We offer comfort for the patient and peace of mind for the family beyond what you might expect. When the resident of a skilled nursing facility begins to decline and he or she desires comfort care rather than hospitalization or aggressive treatment, Hoffmann staff specializes in managing that comfort and enhancing the care provided by facility staff.

Indefinitely. Our patients may continue to receive hospice care as long as they meet hospice criteria. Once on service, they are evaluated on a regular basis by our team of medical professionals. Whenever removing a patient from hospice care is a possibility, patients and their families are always involved in the decision. There is never a rush. In fact, some of our patients have been with us for months.

How are we funded?

Hoffmann’s services are funded, in part, by Medicare, Medi-Cal, and commercial insurance reimbursements. 

Donations to Hoffmann Hospice support the following services:

• Patient and family care
• Medical equipment and supplies
• Ambulance transport
• Medications
• Other needs that may not be covered by Medicare or insurance

At Hoffmann Hospice, our goal is never to deny care to those in need. Every donation is deeply appreciated and supports the non-profit work of servicing the terminally ill and their families.

Additional issues for consideration include:

The individual or representative must sign a consent form electing to participate in the Hospice program.

The patient’s home environment must be reasonably safe, conducive to Hospice care and free from risk to staff life or health. Risks may include animals that bite, guns, excessive drinking or infestation. It is at the discretion of the healthcare professional to determine if the home is a safe environment for practice. Non-compliance may be considered a cause for termination of service.

The individual must live within the areas of served by Hoffmann Hospice. Please reach out through our  Contact page  for more information about Service Areas.

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Emergency care utilization and the Medicare hospice benefit for patients with poor-prognosis cancer

Ziad obermeyer.

1 Department of Emergency Medicine, Harvard Medical School, Boston, MA

2 Department of Emergency Medicine, Brigham & Women’s Hospital, Boston, MA

3 Ariadne Labs, Brigham and Women’s Hospital and Harvard School of Public Health, Boston, MA

Alissa C. Clarke

Maggie makar, jeremiah d. schuur, david m. cutler.

4 Department of Economics, Harvard University, Cambridge, MA, and National Bureau of Economic Research, Cambridge, MA

Associated Data

Background/objective.

There is increasing interest in the relationship between palliative and emergency care. We compared patterns of Emergency Department (ED) utilization and inpatient admission rates for elderly patients with poor-prognosis cancers who enrolled in hospice to those of similar patients who did not.

Matched case-control study.

Nationally-representative sample of Medicare fee-for-service beneficiaries with poor-prognosis cancers who died in 2011.

Participants

Hospice beneficiaries, matched to non-hospice beneficiaries on time from poor-prognosis cancer diagnosis to death; region; age; and sex.

Measurements

ED utilization and inpatient admission rates before and after hospice enrollment for hospice beneficiaries, compared to equivalent control periods.

Of 272,832 matched beneficiaries, 81% visited the ED in the last 6 months of life. At baseline, daily ED utilization and admission rates were not significantly different between hospice and non-hospice beneficiaries. By the week before death, non-hospice patients averaged 69.6 ED visits/1000 beneficiary-days vs 7.6 for hospice beneficiaries (rate ratio: 9.7, 95% CI: 9.3–10.0). Inpatient admission rates in the last week of life were 63% for non-hospice and 42% for hospice beneficiaries (rate ratio: 1.51, 95% CI: 1.45–1.57). Of all hospice beneficiaries, 28% enrolled during inpatient stays originating in EDs; they accounted for 35.7% (95% CI 35.4%–36.0%) of all hospice stays <1 month compared to 13.9% (95% CI 13.6%–14.2%) of stays >1 month.

Most Medicare beneficiaries with poor-prognosis cancer visited EDs at the end of life. Hospice enrollment was associated with lower ED utilization and admission rates vs non-hospice care. Many patients enrolled in hospice during inpatient stays that followed ED visits, a phenomenon linked to shorter hospice stays. These findings must be interpreted carefully given potential unmeasured confounders in matching.

INTRODUCTION

Fifty-one percent of elderly patients visit the Emergency Department (ED) in the last month of life. 1 The decisions made for these patients in the ED—about mechanical ventilation, invasive procedures, intensive care admission, and other high-intensity interventions 2 – 4 —have immediate and downstream implications for patients’ care and quality of life, as well as for health care costs. 2 , 5 , 6 As a result, there is growing interest in promoting palliative and hospice care in the emergency setting. 7 , 8

While it has been shown that hospice enrollment in elderly Medicare patients is associated with fewer ED visits in the last month of life, 1 significant questions remain regarding how much of this effect can be attributed to hospice: patients who choose hospice may simply be less likely to seek emergency care irrespective of their hospice enrollment, and there is little evidence on the trajectories of ED utilization before and after enrollment. In addition, the pattern of hospital admissions resulting from ED visits among hospice patients compared to non-hospice patients is unknown. As a result, the impact of hospice on ED utilization, and, more broadly, the relationship between emergency care and hospice, remain poorly understood.

We studied patterns of ED utilization and ED admissions before and after hospice enrollment in a large cohort of Medicare beneficiaries with poor-prognosis cancer. We compared those enrolled in the Medicare hospice benefit to matched controls receiving non-hospice care over the last year of life, and investigated the association of hospice care with ED utilization and ED admission rates over similar periods before death. We hoped to provide a more complete picture of the relationship between hospice and ED utilization and inform current debates about the role of palliative care in the ED.

Study Design and Participants

We conducted a matched case-control study of all hospice-eligible, fee-for-service Medicare beneficiaries with poor-prognosis cancer who died in 2011. We adapted a palliative care screening instrument from a large cancer referral center to generate a list of International Classification of Disease (ICD) codes corresponding to poor-prognosis malignancies, which we define as those with a high risk of death within six months, including poor-prognosis primary cancers ( e.g. , lung, pancreatic, brain), any metastatic malignancy, and any hematologic malignancy specifically designated as unremitted or relapsed. 9 The diagnoses used in the algorithm were developed by clinicians treating a wide range of cancer patients to identify those with poor prognoses and lack of options for curative treatments. Beneficiaries with any one of these ICD codes in the Medicare 100% inpatient, outpatient, and hospice files from 2008 to 2011 were considered eligible for hospice, which is available to those with terminal illness and expected survival of less than 6 months, and were included, correcting for use of outpatient “rule-out” codes. 10 Both hospice beneficiaries and non-hospice controls were thus eligible to enroll in hospice. Hospice enrollees were identified as those with at least 1 hospice claim submitted after the first cancer diagnosis.

To verify that this method successfully captured patients at high-risk of mortality, we calculated one-year mortality in a prior year of Medicare data. The mortality rate of this cohort, 31% in the year after first diagnosis, was similar to and only slightly lower than mortality rates in previous research on poor-prognosis cancer. 11

Our method of matching hospice enrollees with non-hospice controls is described in more detail elsewhere. 12 Briefly, we first matched beneficiaries according to individual-level characteristics, performing one-to-one exact matching of hospice beneficiaries to non-hospice patients on hospital referral region, age, sex, and time from first poor-prognosis cancer diagnosis to death (in months). This last variable was used as a proxy for disease course and severity. Because cancer patients tend to experience a decline in health at least 3 months before death, 13 we assumed that both non-hospice and hospice beneficiaries included would likely have had sufficient time to consider and enroll in hospice. With their diagnoses of poor-prognosis cancer, all patients in both groups were eligible.

Using a strategy of progressively coarsening exact matching (CEM), 14 beneficiaries were matched by the finest strata of each variable (ZIP code, year of birth, sex, months from diagnosis to death). Remaining unmatched cases were then matched iteratively in increasingly broad categories, up to a maximum of 5-year age intervals, 4-month illness duration intervals, and hospital referral region (HRR). We had initially attempted propensity score matching (PSM), but this generated significant imbalances on important covariates ( eTable 1 ); for example, only 0.8% of matched pairs resided in the same HRR. Thus, we present CEM results here, with PSM sensitivity analysis in the supplemental material ; because of the computationally-intensive nature of PSM, we used a nationally-representative 20% sample of Medicare beneficiaries rather than the 100% sample used for CEM.

Exposure Period

For each pair of matched hospice and non-hospice (control) patients, we defined an exposure period leading up to death. The exposure period was defined as the number of days the hospice enrollee claimed the benefit until death. For each matched pair, this exposure period was applied to the non-hospice control, counting backwards from the control patient’s death. While the chronological time of death differed between the hospice beneficiaries and non-hospice patients, the exposure time before death was equivalent. For example, if a beneficiary claimed hospice for 20 days prior to his or her death, the exposure period for the matched control would also be 20 days prior to the control patient’s death.

We calculated the percent of beneficiaries visiting the ED in the last six months of life; six-month survival is the eligibility criterion for hospice enrollment in beneficiaries with terminal illness. We compared ED utilization and ED admission rates between hospice beneficiaries and matched non-hospice patients at baseline (defined as 1 year prior to the first week of hospice); the week prior to hospice enrollment; and the week prior to death, taking into account the varying duration of the exposure period (in weeks) between hospice enrollment and death.

Statistical Analysis

Balance between case and control groups was confirmed for all variables used for matching by comparing group means or medians. Utilization of health services and medical comorbidity at baseline was measured using the Gagne comorbidity score, a composite mortality scale based on Elixhauser and Charlson indices. 15 Variables describing health services utilization and comorbidity at baseline were not used for matching, because the exposure periods for controls were defined retrospectively based on that of their matched hospice-enrolled pair. ED utilization was calculated per 1000 beneficiaries per day, and ED admission rate was calculated as the number of beneficiaries with an ED visit leading to an inpatient hospitalization as a percent of all beneficiaries visiting the ED. We compared both rates in case and control groups using risk ratios. Finally, we hypothesized that inpatient admission from an ED visit triggered hospice enrollment for some beneficiaries. We calculated the percent of hospice beneficiaries who enrolled during inpatient stays following admission from the ED, and explored the correlation between this phenomenon and length of hospice stay, which has been linked to quality of care. 16 – 19

Study Population and Characteristics

Figure 1 shows the study population and the matching process. A total of 1,572,326 Medicare fee-for-service beneficiaries who died in 2011 were considered for inclusion. Of these, 420,503 had a prior diagnosis of poor-prognosis malignancy, and were thus eligible for hospice. We excluded 1,322 (0.31%) beneficiaries who had missing or non-US ZIP codes, 2,462 (0.59%) who had previously enrolled in hospice, and 12 with invalid dates ( e.g. , hospice or diagnosis dates following death date). In the remaining group, 254,729 patients claimed hospice for a median duration of 15 days (interquartile range [IQR] 5–47), compared to 161,978 patients who did not. The final study cohort consisted of 136,416 matched pairs (84.2% of the non-hospice group).

(A) Generation of the matched cohort. We first identified all Medicare beneficiaries who died in 2011, then selected those diagnosed with poor-prognosis cancer. Beneficiaries with prior hospice enrollment suggesting a preceding terminal illness, as well as those with missing geographic or date of death information were excluded. The remaining set was divided by hospice enrollment and then matched, with 84.2% of the non-hospice group paired.

Table 1 shows baseline characteristics of the study cohort. There were no statistically significant differences between hospice beneficiaries and non-hospice patients for any variables used for matching. Median comorbidity, inpatient admission, and ED visit rates were similar from 2006 to the beginning of the exposure period for both groups. Baseline differences in home health days, clinic visits, and daily expenses in the year prior to hospice were statistically significant: hospice beneficiaries had more days of home health assistance (median: 6 vs 4, difference: 2 [95% CI: 1.7–2.3]) and more clinic visits (median: 1 vs 0, difference: 1 [95% CI: 0.87–1.1]), but lower mean daily expenses in the year prior to hospice ($132.3 vs $141.5, difference: $8.5 [95% CI: 7.5–9.5]). eTable 2 compares the study population to the overall population of all Medicare poor-prognosis cancer deaths in 2011, showing no differences between the included study population and the broader population in terms of age or sex. However, the median time from diagnosis to death was 6 weeks shorter for the study population than for the overall population: the distribution of illness duration was right-skewed ( i.e. , more patients with shorter survival and a long tail of patients with survival times above the median), making it more difficult to match beneficiaries with above-median illness duration and resulting in a likewise right-skewed matched cohort.

Table 1 shows baseline characteristics of the study cohort.

ED Utilization

For the entire study population, 81.3% (95% CI: 81.1%–81.4%) had an ED visit in the last 6 months of life. For hospice beneficiaries, the median hospice stay was 14 days; under 3.7% of stays exceeded 6 months. Figure 2 compares the number of ED visits per 1,000 beneficiaries per day for non-hospice patients and hospice beneficiaries, from 1 year before exposure period until death. We separated beneficiaries into groups based on the length of exposure period ( i.e. , time from hospice enrollment to death, or equivalent period for non-hospice controls). Because it was not feasible to show all 109 groups, and because aggregating different exposure lengths obscured time trends, we show representative groups with exposure periods of 1, 2, and 4 weeks, which together make up 56.4% of the entire cohort, and every 4 weeks from 8 to 30 weeks, which make up 6.1% of the cohort. For each exposure period, the number of ED visits after enrollment was higher for the non-hospice patients than for hospice beneficiaries. Overall, 86.6% (CI: 86.4%–86.8%) of non-hospice patients were seen in the ED in the last 6 months of life, compared to 75.9% (CI: 75.7%–76.2%) in the hospice group (absolute difference: 10.7%, CI: 10.4%–11.0%).

The mean daily number of ED visits per 1000 beneficiaries for non-hospice patients and hospice beneficiaries, from 1 year before the start of the exposure period (week 0) until death. We separated beneficiaries into groups based on the length of exposure period ( i.e. , the length of hospice or non-hospice care before death). Because we could not show all 109 groups, and aggregating groups would obscure time trends, we show representative groups with exposure periods of 1, 2, and 4 weeks, which together make up 56.4% of the entire cohort, and then at 4 week intervals from 8 to 30 weeks, which make up 6.1% of the cohort. Crosses mark the week of death for each group of beneficiaries. The vertical dash line at week 0 marks hospice enrollment and the start of the exposure period. The shaded area around the lines indicates the 95% confidence interval for the mean daily visits.

These trends are summarized in Table 2 , which shows the number of ED visits per 1000 beneficiaries per day at baseline (from 2006 until 1 week before exposure period), 1 week before exposure, and 1 week before death. The ED visit rate was similar for hospice beneficiaries and non-hospice patients in the baseline period (rate ratio: 0.99, 95% CI: 0.98–0.99). In the week before exposure period start, non-hospice patients were approximately half as likely as hospice beneficiaries to visit the ED (46.1 vs 88.1 visits per 1000 beneficiary-days, rate ratio: 0.56, 95% CI: 0.56–0.57). In the final week of life, however, non-hospice patients were almost 10 times more likely than hospice beneficiaries to visit the ED (69.6 vs 7.6, rate ratio: 9.7, 95% CI: 9.3–10.0). Non-hospice patients also visited the ED 10 times more often in the week prior to death than they did at baseline (5.4 at baseline vs 69.6 at 1 week before death), while hospice enrollees’ ED visits increased only slightly (5.2 at baseline vs 7.6 at 1 week before death).

Table 2 shows the number of ED visits per 1000 beneficiaries per day at baseline (from 2006 until 1 week before exposure period), 1 week before exposure, and 1 week before death.

ED Admission Rates

There was no difference in ED admission rates between non-hospice patients and hospice beneficiaries at baseline (rate ratio: 1.0, 95% CI 1.0–1.0) or in the week prior to exposure period start (rate ratio: 0.99, 95% CI 0.99–1.0). In the final week of life, non-hospice patients in the ED were 51% more likely to be admitted than hospice beneficiaries (rate ratio: 1.51, 95% CI: 1.45–1.57). Non-hospice patients were admitted at higher rates in the week prior to death (rate: 0.63, 95% CI 0.63–0.64) than they were at baseline (rate: 0.55, 95% CI 0.55–0.55), while the opposite was true for hospice beneficiaries (0.42 at 1 week before death vs 0.54 at baseline).

Hospice Enrollment Following ED Admission

Of all hospice beneficiaries, 28% enrolled during inpatient stays following admission from the ED. We explored the correlation between ED admission and time between hospice enrollment and death, and found that beneficiaries who enrolled in hospice after being admitted through the ED were more likely to have short hospice stays than those who did not enroll as inpatients. For beneficiaries with less than 1 month of hospice care, 35.7% (95% CI 35.4%–36.0%) started hospice as inpatients after ED admission, while this was only true for 13.9% (95% CI 13.6%–14.2%) of those claiming hospice benefits for more than 1 month. This trend is summarized graphically in eFigure 1 .

Sensitivity Analysis

PSM produced 100% matching of the non-hospice group, for an included cohort of 69,854 beneficiaries. In this cohort, balance on important drivers of cost, most notably geography, was poor, with only 0.8% of matched pairs residing in the same HRR ( eTable 1 ). Nonetheless, general trends in ED visits and ED admissions were similar in PSM and CEM ( eFigure 2 ), as were rates of ED visits and ED admissions ( eTable 3 ).

While a vast majority of Medicare beneficiaries with poor-prognosis cancer visited EDs at the end of life, those enrolled in hospice had significantly fewer ED visits than matched non-hospice patients after hospice enrollment, despite generally similar patterns of ED utilization before enrollment. When hospice beneficiaries did visit the ED, they were also less likely to be hospitalized than non-hospice patients. We also identified a large minority of hospice beneficiaries who enrolled as inpatients following inpatient admission from the ED, a phenomenon linked to shorter hospice stays.

While the lower rate of ED visits among hospice patients had been identified in previous, smaller studies, 1 , 20 an exact understanding of the nature of the correlation demanded a more careful examination of the temporal relationship between the two: because the hospice program requires beneficiaries to forgo curative care, it might be more attractive to patients with a baseline preference for less care. We found that ED utilization was similar between hospice and non-hospice patients at baseline, and observed a significant decrease in ED utilization immediately after hospice enrollment; there was no such pattern in non-hospice patients. Given the temporal pattern, this result was unlikely to be a reflection of baseline differences between hospice and non-hospice populations. The pattern could reflect changes in underlying health status that precipitate hospice enrollment, or a causal effect of choosing hospice. Such causality, however, cannot be determined with this retrospective data. We also found that inpatient admissions from the ED decreased for hospice beneficiaries after enrollment. Given studies suggesting that most patients prefer to stay out of the ED and hospitals in the days leading up to death, 21 the reduction in ED use and admissions indicates that hospice is an important correlate of quality of care at the end of life.

Our findings also highlight important connections between ED utilization, hospital admission, and hospice enrollment, building on prior studies. 22 – 25 We found that nearly one-third of hospice beneficiaries enrolled as inpatients following ED admission, and that these beneficiaries had shorter hospice stays. This phenomenon likely reflects both the growing role of palliative and hospice interventions in the emergency setting and shortly afterwards, and also failures to address palliative care needs earlier in the outpatient setting, 26 as demonstrated in previous work connecting late referrals, emergency utilization, and aggressive end-of-life care. 16 Visits to the ED, and especially admissions from the ED, may represent an important “pause point” for patients with poor-prognosis cancers, and a window of opportunity for emergency care providers to engage with patients in end-of-life care conversations, which could be continued in more depth by oncologists, hospitalists, intensivists, and other providers in the hospital. However, given that these patients had shorter hospice stays, which are increasingly considered indicative of lower end-of-life quality of care, 16 – 19 hospice enrollment in the emergency setting or shortly thereafter is unlikely to represent optimal care. Our results reinforce the need to increase discussion of hospice and palliative care at multiple points in the care of patients with advanced illnesses—including the ED and inpatient hospitalizations, but especially the routine outpatient setting.

There were limitations to this study. In matching, we made assumptions about the correlation between illness severity and illness length: first, that the two were in fact correlated; second, that hospice enrollment was not correlated with illness length. If hospice enrollment were correlated with shorter survival times, then hospice beneficiaries would have been healthier than they appeared from their illness length, a difference that could partially account for the decreased ED visit and ED admissions rates after enrollment. If, however, hospice enrollment were correlated with longer survival times, then hospice beneficiaries would have been sicker than they appeared from their illness length, a difference that would buffer the decrease in ED visit and admissions rates post-enrollment. Since there is some evidence that hospice care may prolong life, 27 the latter seems more likely; our results may thus not capture the full reduction in ED visits and admissions among hospice beneficiaries after enrollment. The group of hospice beneficiaries had higher comorbidity scores, indicating that they may have been sicker than their non-hospice controls. However, if we are correct that illness length was correlated with disease severity, the matching process would have corrected for any such discrepancies.

It is additionally important to point out that while matching according to age, sex, geography, and illness severity captured relevant similarities between two matched patients, we were unable to account for all potential variables and thus cannot say with certainty that the two groups were fully comparable. It is reassuring that, despite matching on only four variables, we were able to achieve balance on a wide range of other measured variables, including median comorbidity, inpatient admissions, and ED visits, increasing our confidence in the matching procedure. However, it is impossible to assess balance on unmeasured covariates, and our results must be interpreted in this light.

There are also potential limitations to generalizability. In order to create a matched cohort balanced on illness duration, demographics, and geography, we excluded a subset of unmatched beneficiaries, potentially biasing results, though additional sensitivity analysis with PSM matched all beneficiaries and produced largely similar results. Other limitations included the restricted analysis to all fee-for-service Medicare beneficiaries with cancer and incomplete data on skilled nursing facility expenses.

Finally, we identified patients with poor-prognosis cancer and high risk of mortality through ICD codes in their Medicare claims files. Such claims-based diagnoses can be inaccurate. These codes may also include cancers that range in severity, though we did specify ICD codes to exclude more indolent cancers with better prognoses ( e.g. , restricting to hematologic malignancies specifically designated as relapsed or not in remission). Additionally, there is, to the authors’ knowledge, no data on the specificity and sensitivity of these codes in predicting survival. However, we verified that this method did indeed identify high-mortality subgroups by calculating one-year mortality in a year of prior claims data, finding 31% mortality. The high mortality of this group suggested that using ICD codes was an effective method to identify patients with a high risk of near-term death. Lastly, all studies on ‘decedents’ encounter an important limitation in identifying patients at high risk of death, since patients’ prognoses may not always be clear to themselves or their providers. We also assume that patients with such poor prognoses were knowledgeable about their eligibility for hospice, when patients may have had hospice presented to them as an option late in the course of their illness and then only after a hospitalization.

In conclusion, most Medicare beneficiaries with poor-prognosis cancer visited EDs at the end of life. Hospice enrollment was associated with decreases in emergency care intensity, including lower ED utilization and rates of inpatient admission compared to non-hospice care. Nearly one-third of hospice beneficiaries enrolled in hospice as inpatients following an ED admission, likely reflecting failures to address palliative care needs in the outpatient setting, and this phenomenon was linked to shorter hospice stays.

Supplementary Material

Supp appendix & table s1-s3 & fig s1-s2, acknowledgments.

Funding sources: NIH (Common Fund/Office of the Director), DP5 OD012161 (PI: Obermeyer)

The authors gratefully acknowledge the help of the Research Data Assistance Center Help Desk at the University of Minnesota. Stacey Tobin, PhD (The Tobin Touch, LLC) contributed to this manuscript and was compensated for editorial assistance.

Conflict of Interest: The authors have no relevant conflicts of interest to report.

Sponsor’s Role: The funders had no role in the design and conduct of the study, in the collection, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript.

Author Contributions: Study concept and design: ZO, DMC. Analysis and interpretation of data: ZO, MM. Literature review: ZO, AC. Drafting and revision of manuscript: ZO, AC, MM, JS, DMC. Obtained funding: ZO. Study supervision: ZO, DMC.

Does Medicare Cover Emergency Room Visits?

• by Christian Worstell
• January 12, 2024
• Reviewed by John Krahnert

Yes, emergency room visits are typically covered by Medicare .

Most outpatient emergency room services are covered by Medicare Part B, and inpatient hospital stays are covered by Medicare Part A.

Medicare Advantage plans (Part C) also cover ER visits . Many Medicare Advantage plans also offer benefits not found in Original Medicare. 

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What Medicare Part A covers

Medicare Part A hospital insurance helps cover:

• Inpatient care in a hospital
• Skilled nursing facility care
• Hospice care
• Some home health care services

Medicare Part A is typically premium-free, as long as you or your spouse paid sufficient Medicare taxes while working.

If you go to the emergency room and are admitted as an inpatient , Medicare Part A helps cover some of the costs related to your hospital stay once your Part A deductible is met .

In 2024, the Medicare Part A deductible is $1,632 per benefit period .

What Medicare Part B covers

Medicare Part B is known as medical insurance and helps cover medically necessary services and preventive services, which can include:

• Doctor’s office visits
• Clinical research
• Ambulance services
• Durable medical equipment
• Mental health services

Medicare Part B may also cover services you receive when you visit the emergency room as an outpatient.

Medicare Part B is optional, and if you enroll in Part B you must also enroll in Part A. Unlike Medicare Part A, which is premium-free for most people, you must pay a monthly premium for Medicare Part B.

The standard Part B premium in 2024 is $174.70 per month.

Emergency room copayments and coinsurance

Even if your emergency room visit is covered by Medicare, you are typically responsible for paying a portion of the costs, known as copayments or coinsurance.

Typically, you pay a Medicare emergency room copayment for the visit itself and a copayment for each hospital service.

How you are charged depends on several factors, including which part of Medicare covers your visit (Medicare Part A, Medicare Part B or both) and whether or not you have met your Part A and Part B deductibles.

In 2024, the Part A deductible is $1,632 per benefit period, and the Part B deductible is $240 per year.

Medicare Part A coinsurance

Generally, if you go to the emergency room and are admitted as an inpatient, Medicare Part A will cover a portion of the costs, and in 2024 you pay:

• $0 coinsurance for each benefit period for days 1-60 spent in the hospital
• $408 coinsurance for days 61-90 in each benefit period
• $816 coinsurance per each “lifetime reserve day” beyond day 90 in each benefit period
• All costs beyond lifetime reserve days

Remember, you must meet your Part A deductible before Medicare will pay its share for covered services.

Medicare Part B copayments

If you go to the emergency room and receive care from a doctor but are not admitted as an inpatient, Medicare Part B will typically cover a portion of your medical costs.

After your Part B deductible is met, you typically pay 20 percent of the Medicare-approved amount for most services, and Medicare pays the rest.

Medicare Advantage plans cover emergency room visits

Medicare Advantage (Medicare Part C) is an alternative to Original Medicare (Medicare Part A and Part B) that provides the same hospital and medical benefits as Original Medicare. This means that Medicare Advantage plans, like Original Medicare, will cover at least some of your emergency room costs.

Most Medicare Advantage plans may also cover benefits not included in Medicare Part A or Part B. 

To learn more about Medicare Advantage plans that may be available in your area and to find out about the emergency room coverage they offer, speak with a licensed insurance agent today.

Explore Medicare Advantage plan benefits in your area

Or call 1-800-557-6059 (TTY: 711) to speak with a licensed insurance agent. We accept calls 24/7!

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at [email protected] .

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How does Medicare cover emergency room costs?

Kimberly Lankford,

The type of Medicare you have determines how it pays for emergency department services.

Original Medicare covers emergency services under Medicare Part B at any U.S. hospital or medical facility that accepts Medicare. However, that care is subject to a deductible and 20 percent copayment. Supplemental insurance, such as a Medigap policy or a retiree plan from your former employer, may cover these out-of-pocket expenses.

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Medicare defines an emergency as an injury, sudden illness or an illness that gets much worse.

If you’re admitted to the same hospital for a related condition within three days, you won’t have to pay the copayment because the visit is considered part of your inpatient hospital stay, covered through Medicare Part A . 

Medicare Part B also covers urgent care visits needed to treat a sudden illness or injury that isn’t a medical emergency. Urgent care visits are also subject to a deductible and 20 percent copayment.

How does Medicare Advantage cover emergency services?

Medicare Advantage plans typically have provider networks and generally charge higher copayments and deductibles or don’t cover out-of-network care at all. But the rules are different for emergency services.  

In this case, Medicare Advantage plans must cover emergency care as an in-network service, even if the hospital or facility isn’t in the provider’s network. But copayments may be different from under original Medicare.  

For example, you may need to pay as much as a $135 copayment for each emergency room visit, whether it’s at an in-network or out-of-network facility. You can compare emergency care copayments for each Medicare Advantage plan in your area using the Medicare Plan Finder . Click on the Plan Details blue button at the bottom of an Advantage plan’s description.

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A different definition of emergencies. For Advantage plans, the Centers for Medicare & Medicaid Services (CMS) considers an emergency medical condition one that, if not treated, could result in:

• Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child. ​​
• Serious impairment to bodily functions.
• Serious dysfunction of any bodily organ or part.

Your emergency medical condition status is not affected if a later medical review found no actual emergency, CMS says. The plan can’t require prior authorization for emergency services.  

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With some MA plans, if you’re admitted to the hospital within 24 hours, you may not need to pay the copayment for the emergency room visit. Instead, it becomes part of your hospital stay.

How to find the details. Specifics vary by plan. See the plan summary on the website of each private plan or evidence of coverage. You can get to these documents through Medicare’s Plan Finder even if you’re not shopping for new coverage.

Log in if you have an account to see a summary of your current coverage. Or navigate through the Plan Finder by entering your zip code, choosing your coverage year, hitting the Continue button, clicking Medicare Advantage Plan (Part C) , tapping the Find Plans button and going though the questions. You don’t need to compare your drug costs, but you do want to get to the list of plans for your area and find your specific plan.

Click the Plan Details button, and on the next page the Plan website link. From there, your provider’s website will walk you through steps to learn information about your plan on its website. You’ll generally see a link to View plan summary or View plan documents within the plan information. Both documents are very detailed but often let you search within for “emergency” so you can find what’s relevant to your situation.

Urgent care also possible. Your Medicare Advantage plan may cover urgent care visits from out-of-network providers. These are nonemergency situations that require immediate medical attention when a network provider is not available, such as when you have a severe sore throat on a weekend and your doctor is off or if you’re traveling outside the plan’s service area.

You’ll have the same copayment as in-network urgent care, which could be around $50. 

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How does Medicare cover emergency ambulance services?

Medicare Part B covers emergency ambulance services , but they’re subject to a deductible and 20 percent coinsurance. A supplemental policy should help cover those.

Part B will pay for ambulance transportation to a hospital or skilled nursing facility if traveling in any other vehicle could endanger your health. This applies to emergency transport in an airplane or helicopter if you need immediate and rapid transport that a ground service can’t provide.

Medicare Advantage, too, covers emergency ambulance services, but like its emergency room coverage, its copay rates can be high. You may have a $300 copay for each one-way trip. See the plan’s evidence of coverage for details. 

Keep in mind

Medicare covers emergency room visits throughout the United States, but it typically doesn’t cover emergency care outside the U.S., except in limited circumstances .  

Some Medigap policies cover foreign travel emergency care with a lifetime limit of $50,000. Some Medicare Advantage plans provide limited coverage for foreign travel emergencies. Specifics vary a lot by plan.

Another option is buying travel insurance , which may provide more coverage for emergency care and medical evacuation when traveling. 

Return to Medicare Q&A main page

Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at  Kiplinger’s Personal Finance  and has written for  The Washington Post  and  Boston Globe . She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.

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Emergency department services

Medicare Part B (Medical Insurance)  usually covers emergency department services when you have an injury, a sudden illness, or an illness that quickly gets much worse.

Your costs in Original Medicare

• 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 your emergency department visit, you don't pay the copayment(s) because your visit is considered part of your inpatient stay.   

To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:

• Other insurance you may have
• How much your doctor charges
• If your doctor accepts assignment
• The type of facility
• Where you get your test, item, or service

Things to know

Medicare only covers emergency services in foreign countries under rare circumstances.

Related resources

• Ambulance services
• Find hospitals
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Is my test, item, or service covered?

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Does Medicare Part A cover emergency room visits?

Medicare Part A does not usually cover emergency room visits unless a doctor admits a person to stay in the hospital as an inpatient. Medicare Part B covers outpatient emergency room visits.

This means that an insured person would need to meet their annual deductible of $198 before Medicare pays for emergency room (ER) visits. Coinsurance of 20% also applies to each visit.

In this article, we expand on which parts of Medicare pay for an ER visit and the costs a person is responsible for under Medicare.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan: Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments. Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%. Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

Which part of Medicare covers ER visits?

Medicare determines which portion of Medicare funds an ER visit based on the doctor’s decision to admit an insured person to the hospital as an inpatient.

Admitting a person as an inpatient means that they need further interventions and medical care before they can return home.

Around 139 million people visited an emergency room in 2017, according to the Centers for Disease Control and Prevention (CDC) .

An estimated 14.5 million of those who made an emergency room visit needed hospital admission. This roughly equates to 10.4% of all emergency room visits.

If a person visits the emergency room without needing admission, Medicare Part B covers a portion of the costs. Part A pays if a person visits the ER, and a doctor admits them to the hospital.

What does Part A cover?

Medicare Part A covers hospital or inpatient care.

A person usually visits the ER at a hospital. However, there is a difference between emergency care at a hospital and being a hospital inpatient.

Medicare Part A specifically covers care when a person stays as an inpatient at the hospital. Medicare considers a person an inpatient when their stay has extended beyond two midnights .

If a doctor admits a person to the hospital, the law requires that they notify the individual that they are an inpatient.

What does Part A not cover?

Medicare Part A covers several services, including inpatient hospital care, skilled nursing facility (SNF) care, and hospice care.

However, this part of Medicare does not cover other services that relate to an ER visit such as:

• ambulance transport
• doctor’s visits
• inpatient treatment or partial hospitalizations for mental health disorders

Medicare Part B is responsible for covering these services.

What does Part B cover?

If a person has to stay at an ER overnight or for longer than 24 hours, hospital personnel should give them a Medicare Outpatient Observation Notice (MOON) .

Receiving a MOON form usually means that Part B, not Part A, will cover the initial ER visit.

Medicare Part B usually covers most aspects of an individual’s visit to an ER, as long the doctor does not admit them to the hospital for reasons related to the visit.

If the doctor discharges a person from the ER to their home, they may be responsible for some or all of the following costs under Part B:

• a copayment for the emergency department visit
• a copayment for hospital services provided, such as imaging studies, medications, or lab work
• 20% of the Medicare-approved amount for a doctor’s services
• the deductible, which applies for doctor’s services

One exception to the ER coverage rules applies when a person returns to a hospital in need of inpatient care within 3 days of their initial visit to the ER.

If the hospital admits the person with the same medical condition, they do not have to pay their Part B copayment twice.

Medicare Part B also pays for ambulance and helicopter transportation when a person urgently requires moving to another location and is unable to get there without medical assistance.

The out-of-pocket expenses for emergency transportation to an ER include the 20% coinsurance. The Part B deductible applies to this amount.

If an ambulance company believes Medicare may not cover their service, they must provide an Advance Beneficiary Notice of Noncoverage .

This often applies if a person requests ambulance transport to an emergency room when their medical situation is not an emergency.

Does Medicare Advantage cover ER visits?

Medicare require that a Medicare Advantage plan covers the same aspects of care as Original Medicare. This means that Medicare Advantage also covers ER visits.

Medicare Advantage, or Medicare Part C, is a bundled plan that a private insurance company administers.

Medicare Advantage includes benefits from Parts A, B, and sometimes D, which covers prescription drug coverage. It may also offer coverage for services, such as vision, dental, and hearing care.

However, some types of Medicare Advantage plan require that a person chooses an in-network treatment provider when receiving emergency medical attention.

A person should review their Medicare Advantage plan so that they know their nearest in-network ER before they require emergency treatment.

Otherwise, they may have to pay more for seeking care at an out-of-network facility.

Find out more about the benefits of Medicare Advantage.

Does Medigap pay for ER visits?

Medicare Supplement Insurance, or Medigap, is a supplemental insurance plan that a person who has Original Medicare may purchase to cover some out-of-pocket expenses, including those for Medicare Part B.

Medicare requires that Medigap plans offer the same benefits regardless of the insurance provider. A person can choose from one of several plans depending upon their healthcare needs and monthly budget.

Most Medigap plans pay for all or part of Part B’s coinsurances or copayments. This may help a person reduce the costs of an ER visit.

Read more about Medigap.

Medicare Part B is the Medicare portion that usually pays for ER services.

An exception applies if a doctor admits a person to the hospital, at which point Medicare Part A would pay for the visit. ER staff should inform a person whether they are an inpatient or outpatient at an emergency room.

Even if a person stays overnight for testing or observation at an emergency room, this does not necessarily mean they are an inpatient.

Last medically reviewed on May 14, 2020

• Emergency Medicine
• Health Insurance / Medical Insurance
• Medicare / Medicaid / SCHIP

How we reviewed this article:

• Advance beneficiary notice of noncoverage. (n.d.). https://www.medicare.gov/claims-appeals/your-medicare-rights/advance-beneficiary-notice-of-noncoverage
• Ambulance services. (n.d.). https://www.medicare.gov/coverage/ambulance-services
• Emergency department visits. (2017) https://www.cdc.gov/nchs/fastats/emergency-department.htm
• Emergency department services. (n.d.). https://www.medicare.gov/what-medicare-covers/whats-not-covered-by-part-a-part-b
• Fact sheet: Two midnight rule. (2015). https://www.cms.gov/newsroom/fact-sheets/fact-sheet-two-midnight-rule-0
• Medicare outpatient observation notice (MOON). (2020). https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON
• What Part A covers. (n.d.). https://www.medicare.gov/what-medicare-covers/what-part-a-covers
• What's not covered by Part A and Part B? (n.d.). https://www.medicare.gov/what-medicare-covers/whats-not-covered-by-part-a-part-b
• What Part B covers. (n.d.). https://www.medicare.gov/what-medicare-covers/what-part-b-covers

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