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?
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?
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:
What does this mean for you? Let’s look at an example, supposing you stayed in the network in either case.
Urgent Care Center
|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.
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.
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Your Action Plan: Get the Care You Need
When a serious illness or injury strikes:
If you’re not sure what constitutes an emergency or what emergency costs are covered, ask your insurer or check your plan documents.