Does Health Insurance Cover Urgent Care?

If you need prompt medical attention, you have two main options — an urgent care center or the emergency room. The former is definitely the more affordable option, but in what situations is it applicable, and does health insurance cover these visits?

The Typical Cost of an Urgent Care Visit

Urgent care centers typically treat patients with health insurance and those without, but the costs may vary significantly. While certain centers offer discounted rates to uninsured individuals, the amounts may still be high, depending on the treatment.

How Much Is Urgent Care With Insurance?

Urgent care is typically covered by insurance, but there are some factors to consider. When seeking an appropriate center, look for a facility that falls into your provider’s network. Some plans, like the preferred provider organization (PPO), typically allow you to receive treatment at a center outside of their network, but you may pay a significantly higher fee. Other plans, like the exclusive provider organization (EPO), only provide coverage for in-network facilities, except in an emergency.

Generally, going in with insurance is much smoother and less stressful than seeking immediate care without insurance. However, there are some costs to consider:

  • Copay: When you check in to an urgent care center, you’ll usually need to pay an out-of-pocket sum. Your insurer should let you know precisely what your copay is so you know what to expect.
  • Deductible: The amount you owe before your coverage kicks in is known as the deductible. Once you reach this amount, your provider will pay the previously stipulated portion of costs.
  • Balance billing: If you go to an out-of-network urgent care center, your insurer might send you a balance bill. You’ll have to pay the difference between their allowed amount and the total charge. To avoid this, ensure the urgent care facility participates in your health care plan.
  • Coinsurance: Insurance policies typically require you to pay a percentage of the cost once you hit the deductible but before reaching your out-of-pocket maximum. Check your maximum annual out-of-pocket costs to learn how much you could be expected to pay.

How Much Is Urgent Care Without Insurance?

Most people don’t realize the importance of health insurance until they need medical care. Here are some common urgent care procedures and the average amounts you can expect to pay without insurance:

  • Annual wellness exam: $138.20
  • Blood sugar test: $32
  • Flu shot: $35.29
  • Pregnancy test: 43.13
  • Nebulizer machine: $98
  • Up to five stitches: $149.50

What’s the Difference Between Urgent Care and the Emergency Room?

An urgent care center typically offers similar services to family medicine practices. They’re ideal for when you need minor medical attention. Similar to the emergency room (ER), urgent care facilities are typically open beyond standard office hours and may also have some equipment found in the ER, such as nebulizers and X-ray machines. The cost is similar to that of primary care facilities, and the staff typically consists of family physicians, assistants and nurse practitioners.

Patients who require minor medical attention, such as a few stitches, should consider an urgent care center instead of the ER. Urgent care is also an excellent option for patients who are unable to meet with their primary physician but need assistance outside of office hours. While urgent care does typically take Medicare and other insurance plans, some centers may still require you to pay a fee. Many urgent care rooms also offer virtual Telehealth options for added convenience. If your condition is more severe than the center can attend to, they’ll usually refer you to the ER.

Emergency rooms are also an option for patients who need care outside of office hours, but the charges are significantly higher. In fact, studies show that the cost of an emergency department visit is, on average, 10 times higher than the cost of visiting an urgent care center. It’s important to note that emergency departments are fully equipped to address more serious health concerns, whereas urgent care facilities are center-dependent but usually won’t take in severe emergency cases.

When Should You Go to an Urgent Care Facility?

If you need to see your physician, but it’s the weekend or outside of their working hours, you can receive similar treatment at an urgent care facility. Ask yourself if your condition is treatable with prescribed medicine or if your symptoms are so severe that a typical doctor’s visit won’t bring you relief.

There are more than 139 million emergency department visits every year, and many of these cases are nonurgent and able to be treated at a typical doctor’s office — it’s safe to say that if your symptoms are mild, go to an urgent care facility instead. You can often get the same type of treatment you would at the ER. Here are some situations that will suit a visit to urgent care instead of the ER:

  • Moderate symptoms like coughing and sinus congestion
  • Minor physical injuries like small burns or bruises
  • Small wounds requiring only a few stitches

When Should You Go to the Emergency Room?

While the cost of ER services may be higher, your life is precious, so even without insurance, you should go to the emergency room when needed. Urgent care centers can take care of most minor incidents, but if you’ve been in an accident or are extremely ill, call an ambulance immediately. Go to the nearest emergency department if you or someone you know is experiencing these severe symptoms:

  • Seizures lasting more than a minute
  • Being unable to breathe
  • An injury to the neck or spine
  • Severe burns
  • An electric shock or lightning strike
  • Severe chest pain or pressure
  • Choking
  • Head injury with fainting, passing out or confusion

Will Your Health Insurance Cover Emergency Care?

The Affordable Care Act (ACA) states that compliant health care plans must provide coverage for emergency services. However, be sure to check the details of your plan, as some offer different options for emergency care and urgent care rooms. You’ll usually pay a flat fee out of pocket for both ER and care centers, but the copay for urgent care centers is significantly more affordable.

While health insurance does cover urgent care, verify beforehand that the center you plan on visiting accepts your coverage and that your provider accepts that care center.

Can You Visit Any Urgent Care Center?

If you require urgent care, you can visit any center to receive the help you need. While you can go to urgent care without insurance, you should expect to pay the flat fee and treatment cost out of pocket immediately. While some facilities offer discounted rates or payment plans, you should find out before checking in.

Insurance does remove some of the stress from seeking urgent care since you’ll have peace of mind that your provider will cover some or all of the treatment fees. That being said, you should still check that the center is in your provider’s approved network and that your treatment is covered. For instance, if maternal benefits haven’t yet kicked in, you may be liable for the fee of an ultrasound at an urgent care center.

Contact Health for California for Health Coverage Assistance

Health for California Insurance Center offers a range of affordable plans for families and individuals. The online process takes up to 10 minutes — all you have to do is fill out our confidential form, and we’ll give you free quotes from the best providers in only 30 seconds. You can also check out our health care blog to stay updated with the latest policy changes and medical plan news.

Not sure how Obamacare affects your health care plans in California? Learn how the ACA works in California, including benefits, costs and enrollment.

Covered California is the Golden State’s official health exchange marketplace where individuals, families and small businesses can find high-quality, low-cost California government health insurance.

Learn about Obamacare income guidelines in California using our income limits chart, and see if you’re eligible for government assistance.

Learn about the Covered California website. Find easy online enrollment. Set up your account, log in, buy insurance and more on the California health marketplace website.