Medicare Advantage Coverage Away From Home: Urgent and Emergency Care on a Trip

You winter in another state, or you visit family across the country. Then you get sick on the trip. Will your Medicare Advantage plan pay? For a true emergency, yes. Federal rules require every Medicare Advantage plan to cover emergency care anywhere in the United States, with no prior approval and no network test. Urgent care while you are away from home is covered too, under rules this guide sets out. Routine care on a trip is where plans split. This guide draws the three lines, so a trip does not turn into a billing fight. Our /medicare-advantage/ hub holds more guides for plan members.

Emergency care: covered anywhere in the country

An emergency is a sudden illness or injury that a prudent person would see as a threat to life or health if care waited. Chest pain, a fall with a head strike, and heavy bleeding fit that test. Under federal rules, your plan must pay for emergency care no matter where in the United States you get it. The hospital does not need to be in your plan network. You do not need a referral. You do not need to call the plan first.

Your cost for emergency care is your plan's own emergency copay, and the plan must treat the visit as if you got care in its network for that cost. Plans set that copay in their own documents. This guide states no amount, since no figure for it exists in the sources this guide may use. If a bill later shows a higher charge for emergency care, call the plan and cite the emergency rule.

Once you are stable, the rules change. The plan can ask to move your ongoing care to a network provider, or to approve the next steps. That follow-up care is called post-stabilization care, and the plan's normal rules can apply to it.

Urgent care: covered while you are away

Urgently needed care sits one step below an emergency. It is care for an unforeseen illness or injury that needs prompt help but is not life-threatening: a sprain, a fever, a cut that may need stitches. Your plan must cover urgently needed care when you are away from the plan service area for a short time, or when the network is not open to you, and it is not reasonable to wait until you get home.

Two limits ride on this rule. The trip must be a short one. A person who has moved away for good is not on a trip. And the need must be real and prompt. A check-up you could have set up at home does not become urgent care just because you are away. Your plan's urgent care copay applies. The plan documents state that amount.

Routine care: the plan type decides

Routine care is the care you plan ahead: a check-up, a specialist visit you booked weeks out, a test that can wait. On a trip, your plan type decides who pays.

Our guide on Medicare Advantage dental, vision, and hearing benefits shows how plan extras work, and our guide on switching from Medicare Advantage back to Original Medicare covers the exit route if a plan's network no longer fits your life.

• HMO plans tie you to a network in the service area. Routine care outside that network is most often not covered at all. Some HMO plans sell a visitor or travel feature. Most do not. Check before you travel, not after.
• PPO plans let you see providers outside the network. The plan pays a share of routine care on a trip, and you pay more than you would at home. The plan documents show both cost levels.
• Special Needs Plans and other plan types follow their own network rules. The same check applies: ask the plan before the trip.

Who pays for what

• Your Medicare Advantage plan pays for emergency care anywhere in the United States, under the federal emergency rule, at your plan's in-network cost level.
• Your plan pays for urgently needed care while you are away for a short time and cannot wait to get home, at your plan's urgent care cost.
• For routine care on a trip, a PPO plan pays its out-of-network share. An HMO plan most often pays nothing outside its network.
• Original Medicare is not your payer while you are in a Medicare Advantage plan. The plan is. A Medigap policy does not work with a Medicare Advantage plan and adds nothing on a trip.
• Medicaid can help members who hold both Medicare and Medicaid, under state rules.
• You pay the rest: plan copays, and the full cost of routine care your plan does not cover away from home.

Sample situation

Dan is 71 and has a Medicare Advantage HMO plan. He visits his son in another state for two weeks. On the fourth day, he falls on a curb and his wrist swells fast. His son drives him to the nearest urgent care clinic, which is not in Dan's plan network. The clinic treats the sprain and takes an X-ray. Because Dan is away from home for a short time and the injury could not wait two weeks, the visit counts as urgently needed care, and his plan must cover it at his urgent care cost. A week later, back home, Dan books his normal check-up with his own doctor. Dan also asks his plan, before his next trip, what it would pay for a routine visit out of state. The plan tells him routine care outside the network is not covered under his HMO. He now knows the line before he needs it. Dan keeps the clinic receipt in his trip folder, in case the plan asks for it.

Before your next trip

Call your plan and ask three things. Ask what number to call in an emergency away from home. Ask how the plan treats urgent care while you travel. Ask what routine care, if any, the plan pays for outside the service area. Write the answers on a card and keep it with your plan card. If you now spend months each year in a second state, that is a sign to shop in the fall for a plan that fits both homes. Our /medicare-advantage/ hub can help you weigh that choice.