📋 Plan Emergency Coverage Rules
✅ Emergency Care Is Covered Nationwide
All Medicare Advantage plans must cover emergency care anywhere in the country — even out-of-network.
Federal law prohibits your plan from penalizing you for going to any ER in a genuine emergency.
Do not delay going to the ER to find an "in-network" facility.
⚠️ Observation vs. Inpatient Status
"Observation" = outpatient — Medicare Part B applies (higher cost-sharing for skilled nursing after).
"Inpatient" = admitted — Medicare Part A applies (3-day rule for skilled nursing care).
Ask your doctor at the ER: "Am I being admitted as inpatient or placed in observation status?"
The difference can cost thousands of dollars.
📋 Inpatient Notification Requirement
If admitted from the ER, contact your plan within 48 hours for inpatient notification if required.
⚡ Expedited Coverage & Appeal
⚡ If Your Plan Is Delaying Urgent Care
Your plan must respond to an expedited coverage determination within 72 hours
(24 hours for urgent Part D drugs). If waiting could seriously harm you, say these words:
"I need an expedited coverage determination because waiting could seriously harm my health."
Appeals Process — Fast Reference
Step 1 — You Are Here
File an Expedited Coverage Determination
Call your plan NOW. Say you need expedited review. Plan must respond within 72 hours.
Step 2 — If Denied
Expedited Reconsideration (IRE)
Automatically forwarded to Independent Review Entity. Decision within 72 hours (expedited).
Step 3 — If Still Denied
ALJ Hearing
Request within 60 days of IRE decision. Amount in controversy ≥ $190 (2026).
Step 4
Medicare Appeals Council
Request within 60 days of ALJ decision.
80%+ of denied appeals are overturned when patients follow through.
Get free help from a SHIP counselor: shiphelp.org
✅ ER Preparedness Checklist
What to Bring
🪪Medicare card (red, white, and blue)
💳Your MA plan ID card — give this to ER staff, not just your Medicare card
💊Medication list or all medication bottles
📞Emergency contacts list
📄Advance directive / living will (if available)
👨⚕️Doctor contact list — names and phone numbers
What to Tell the ER
💬Tell ER staff: "I have Medicare Advantage" and give them your plan ID card
❓Ask: "Am I being admitted as inpatient, or am I in observation status?"
✍️Get the name of every doctor who sees you
After the ER
📞Call your plan within 48 hours if admitted inpatient
📋Request an itemized bill — billing errors are common
📁Keep all paperwork: discharge summary, EOB statements
⚡If denied, appeal immediately — 80%+ of denied appeals are overturned
🏥 Find Nearby Emergency & Urgent Care
✅ In a True Emergency — Go to the Nearest ER
Do not wait or drive further to find an in-network facility. Emergency care is covered everywhere.
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Enter your ZIP code above to find nearby hospitals with emergency rooms
Tip: Call your plan's customer service number to confirm which facilities are in-network.
In-network costs less (out-of-pocket), but emergency care is covered everywhere.
Data source: CMS Hospital General Information