Emergency Care and Urgent Care

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Summary

Your plan’s rules and costs may differ for some types of care. Knowing these rules can help you control your costs and get the right care in the right setting.

  • Emergency care. Many plans cover some part of the cost of emergency care for sudden, serious sicknesses or injuries. They may cover emergency care even if you are outside the plan’s network. Once your condition is stable, you will often be moved to a doctor or hospital in your plan’s network for further care.

You will often pay a copay, which is sometimes waived if you are admitted to the hospital. Keep in mind that most plans only cover visits to the emergency room (ER) for “true” emergencies. If you visit the ER for non-emergency care, you could have high out-of-pocket costs.

  • Urgent care. When you need care quickly for an illness or injury that is not a “true emergency,” you can visit an urgent care center. These centers offer care after hours and on weekends, when your family doctor may not be available. But, they are not equipped to deal with major traumas or health problems.

Most health plans have urgent care centers in their networks. Your copay or coinsurance for an urgent care visit will often be lower than for an ER visit.

Remember:

  • In a serious emergency or one that threatens your life, seek care first. Call your insurer once your health problem is stable.
  • Many insurers have 24-hour helplines for members. If you’re not sure whether to go to the ER or some other setting, call and ask.
  • Visit your plan’s website to find urgent care centers in your network.

It can be frightening when a sudden illness or injury strikes, especially if your regular doctor is not available. You need to make a choice quickly about where to get the medical attention you need. But, it’s also important to have all the facts before you seek care.

What Are My Options?

  • Emergency Rooms: Emergency rooms are open 24 hours a day for potentially life-threatening emergencies. Many plans cover some portion of emergency care no matter where you are, even out of their network area. Once your condition is stable, you will generally be moved to an in-network provider for follow-up care. You may have an ER copayment, coinsurance or deductible. You may also have an additional out-of-network charge. If you have questions about what constitutes an emergency, or about what emergency costs are covered, call your insurer.
  • Urgent Care Centers: These centers have extended hours and are not equipped to deal with major medical traumas or conditions. They are intended to provide treatment for less serious conditions after regular office hours, or when your Primary Care Physician is not available. Your copay or coinsurance for an urgent care visit will often be lower than the copay or coinsurance for an ER visit. Urgent care centers may be attached to a hospital, or may be separate facilities. Most health plans include urgent care centers in their networks.

It’s important to remember that most health plans will not pay for ER visits for what they consider to be non-emergency care. In determining what is a true emergency, most plans are required to abide by the “Prudent Layperson Standard” under PPACA, which defines a medical emergency as “A condition with acute symptoms of sufficient severity (including severe pain) that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in—(i) placing the health of the individual (or an unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part."  If you visit the ER for non-emergency care, you could end up with high out-of-pocket costs.  On the other hand, you should not delay going to the ER for symptoms that could signal a serious health problem, since this could give rise to serious issues.  Some plans have nurse-advice lines you can call to help you with this decision, or you can call your doctor for advice.

 

How is Emergency Care Different from Urgent Care?

Cost

It costs a lot of money for hospitals to support all the equipment and staff that an ER requires. So, visits to the ER generally cost much more than those to a doctor’s office or an urgent care center. Plus:

  • Your copay or coinsurance for ER visits will generally be higher than the copay for doctor’s or urgent care center visits.
  • There may be two separate charges – one from the Emergency Room, and one from the physician who treats you. (For a regular office or urgent care visit, there is usually only one charge.)
  • Your plan may not pay for the ER visit if they determine your condition was not a true emergency, leaving you to cover the full cost yourself. That means if you visit the ER for routine care, like a check-up or vaccination, you could be left with a big bill.

What does this mean for you? Let’s look at an example, supposing you stayed in the network in either case.

  Urgent Care Center Routine Care Emergency Room Routine Care
Your Copay $20 $50
Provider’s Fee $300 $1,000
Your Plan Pays $280 ($300 - $20) $0
You will owe $20 $1,000

Your plan’s actual provisions may be different from those we have used in this example.  Be sure to check your plan booklet, your insurer’s website, or call your insurer so you can be sure you understand how your plan works.

Wait Time

Emergency Rooms treat the patients with the most serious conditions first, so patients with less urgent needs will often wait longer to see a doctor. Urgent Care centers only see patients with routine conditions, and it’s usually on a first-come, first-served basis. 

Your Action Plan: Get the Care You Need


When a serious illness or injury strikes:


  • Consider the severity of your condition, and your options. Do you need care immediately, or can it wait? Is it during the day when your regular doctor is available, or after regular office hours?
  • Many insurers have 24-hour helplines for members. If you’re not sure where to go for care, call and ask.
  • If you choose to visit an Urgent Care Center, you can avoid high out-of-pocket costs by checking your plan’s website or calling your insurer to find a center near you that is in your network.

If you’re not sure what constitutes an emergency or what emergency costs are covered, ask your insurer or check your plan documents.

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