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’re outside the plan’s network. Once your condition is stable, you’ll often be moved to a
doctor or hospital in your plan’s network for further care.
You’ll often pay a copay, which is sometimes waived if you’re 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 nonemergency care, you
could have high out-of-pocket costs.
Urgent care. When you need care quickly for an illness or injury that isn’t 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. You can use the “Urgent Care Costs” tab on our Medical Cost Lookup Tool to look up
typical costs in your area for the most often used urgent care services and procedures. This will give you the typical
costs in an urgent care center if you’re uninsured or going out of network.
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 isn’t 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’ll generally
be moved to an in-network provider for follow-up care. You may have an ER copay, 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’re
intended to provide treatment for less serious conditions after regular office hours, or when your Primary Care
Physician isn’t 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. You can use the “Urgent Care Costs” tab on our Medical Cost
Lookup Tool to look up typical costs in your area for the most often used urgent care services and procedures. This will
give you the typical costs in an urgent care center if you’re uninsured or going out of network.
It’s important to remember that most health plans will not pay for ER visits for what they consider to be nonemergency
care. In determining what is a true emergency, most plans are required to abide by the “Prudent Layperson Standard”
under the Affordable Care Act, 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 nonemergency 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 checkup 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 or your insurer’s website, or call your insurer so you can be sure you understand how your plan works.
Wait Time
ERs 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.