- Most insurance plans cover urgent care visits, but coverage specifics depend on the plan and the chosen urgent care center. Familiarity with insurance terms like premiums, copays, and deductibles is essential.
- Urgent care is generally more cost-effective than emergency rooms, with ER visits costing significantly more due to their capability to handle severe emergencies.
- Before visiting, it's crucial to check if the urgent care accepts your insurance, understand potential out-of-pocket expenses, and always bring your insurance card. Some clinics might require upfront payment or even deny treatment for non-payment.
Illness and injuries happen unexpectedly—often causing you to need medical care on short notice. When you’re dealing with a sudden need for medical care, going to urgent care is a great way to avoid the high costs of an emergency room and long wait times for an appointment with your primary care physician.
Before you head out to urgent care, you might be wondering if your insurance will cover your visit. The good news is that most insurance plans do offer coverage for urgent care visits. However, it will depend on your specific plan and the urgent care you visit.
Below you’ll find a comprehensive guide to assist in understanding when your insurance will cover urgent care and how much you can expect in out-of-pocket fees.
Understanding Common Insurance Terms
Before we dig into how insurance and urgent care work together, it's important to understand some of the terms you will come across frequently.
Premiums, Copays, and Deductibles
Even if your insurance plan covers urgent care, you may still be responsible for out-of-pocket expenses known as copays and deductibles.
A premium is the monthly cost of staying enrolled in an insurance plan. For some employees, your employer may help cover some of the costs of your premium.
A copay is a fixed amount that you pay for a medical service. For example, you may have a $20 copay for an urgent care visit or a $100 copay for an emergency room visit.
A deductible is the amount you pay before your insurance starts covering costs. For example, you may have a $1000 deductible, which means you will need to pay for $1000 worth of health services before your insurance kicks in.
Each insurance plan has a predetermined amount for copays and deductibles. You should get all this information during the insurance enrollment process.
Different Types of Insurance Coverage
Insurance coverage refers to what services and treatments your insurance plan will pay for. These services may include urgent care visits, hospitalizations, prescription medications, lab tests, X-rays, and more. Depending on your plan, you may have different levels of coverage for different types of services, according to Investopedia.
Health Maintenance Organizations (HMOs)
HMO plans require you to stay with in-network providers. This means that you are unable to visit a provider or urgent care that is not included on their list of approved providers. If you need to see a specialist, you will need a referral from an in-network provider.
Preferred Provider Organizations (PPOs)
According to Insurance.com, the PPO plan is a popular coverage type for employees. In 2021, around 46% of employed adults have a PPO plan through their employer-provided insurance company, according to Insurance.com. With a PPO plan, you can be flexible with what providers you see. This is because you can see out-of-network providers without a referral or pre-approval. Additionally, PPO plans offer a higher premium charge in exchange for lower co-pays.
Point of Service Plan (POS)
POS plans are less popular (accounting for around 9% of health plans in 2021, according to Insurance.com). They allow freedom in choosing where you get care, however, you will need to file your own claims if you choose to go to an out-of-network provider.
Medicare is a federal insurance plan for those who are over the age of 65 or with certain disabilities or conditions, according to Health and Human Services.
The Health and Human Services Department defines Medicaid as a joint federal and state program that offers health coverage to some people with limited income. This includes pregnant and postpartum women, as well as children under the age of 18.
High Deductible Health Plan (HDHP)
HDHP plans have grown in popularity over the last several years, according to Insurance.com. They are popular because of their lower premium costs and the addition of a Health Savings Account (HSA) to help offset the higher deductible costs.
Exclusive Provider Organization (EPO)
EPOs require you to take in-network and often have a limited number of in-network providers, according to Insurance.com. You will also need to get pre-approval for some services.
Where to Find Insurance
Many employers offer insurance plans as a benefit of working for them. However, if you are unemployed, self-employed, or work for a small company that doesn’t offer insurance benefits, you may want to consider getting health insurance on your own. Companies that are popular for health insurance include:
- Blue Cross Blue Shield
- United Healthcare
Additionally, you can get affordable healthcare coverage through the Affordable Care Act (ACA) through their marketplace.
When Does Insurance Cover Urgent Care
According to the Affordable Care Act (ACA), emergency care is one of the required essential health benefits for all long-term health insurance. However, not all insurance companies view urgent care visits as emergency care.
Because insurance providers have specific provider networks, you might find that some urgent care centers are within the network and others are not. Going to a clinic that’s within the insurance plan’s network is a vital way to ensure you get the coverage you need.
How Urgent Care Clinics Work With Insurance Companies
Each insurance provider determines if it covers urgent care centers or not. In many cases, insurance providers will cover urgent care, but patients will be expected to pay a co-payment or co-insurance. In some rare cases, an urgent care clinic may not accept your insurance, even if your insurance provider would otherwise pay for the care.
Because of this, it is always best to call ahead and check to see if your urgent care clinic accepts your insurance, and to be aware of your out-of-pocket expenses when it comes to urgent care.
Urgent Care vs. Emergency Room
In general, emergency room visits are more expensive than urgent care visits. In fact, an NIH study in Texas showed emergency room costs over $2,000 per visit, while urgent care was only around $165 per visit.
This is because emergency rooms are equipped to handle severe medical emergencies and thus, they have more advanced medical equipment and resources available. As a result, insurance plans may have higher co-pays or deductibles for emergency room visits when compared to urgent care visits.
Going to Urgent Care With Out-of-State Insurance
If you are traveling out of state or you work for an employer that is based in another state, your insurance coverage may change slightly. Some insurance plans cover services in other states, while others may not, according to Insurance.com. This is another reason why it is so important to understand your coverage details.
Even when your insurance plan does cover urgent care services in other states, you still need to be prepared to pay your deductible or co-pays. The amount you pay may be different than what you would pay for the same services in your home state, according to Insurance.com.
Finding an Urgent Care Center That Accepts Your Out-Of-State Insurance
If you’re traveling, you should check with your insurance provider before you go. They can explain your out-of-state coverage and even help you find providers who are along your route or at your destination that accept your insurance. Don’t forget to also bring your insurance card and prescription card (if you have one) along with you.
Going to Urgent Care Without Insurance Card
If you find yourself going to urgent care without your insurance card, don't worry—there are still options available to you. However, there are a few extra steps involved.
First, you can check for your insurance information by logging into your online portal through your insurance’s website. You may be able to download a digital copy of your insurance card this way. If not, you can still get your policy number, group number, and other information.
If you are unable to find your information through an online portal, you can call your insurance provider and get the information from them over the phone.
Can Urgent Care Deny You Treatment for Non-Payment?
When you visit an urgent care clinic, you may be asked to pay your copay upfront. Some urgent care clinics may require you to pay the full price of the visit if you do not have insurance or if they don’t accept your insurance.
According to Debt.org, some urgent care clinics can turn you away if you are unable to pay. Keep in mind that most urgent care clinics accept cash or credit cards. Some clinics may also offer payment plans or financial assistance programs for patients who can't afford to pay their bills in full.
What to Expect During an Urgent Care Visit
When you arrive at urgent care, you will first check-in at the registration desk. Here you will provide your personal information, insurance information, and a brief detail of why you need to get medical care. During this process, you may be asked to pay your copay or the price of your visit if your deductible hasn’t been met yet.
Some urgent care clinics have a triage area. Once you are checked in, a triage nurse will quickly evaluate you and decide how your condition ranks compared to others who need care. For example, if you have a minor illness and someone else has more severe symptoms, they will likely be seen sooner than you.
Either in triage or when you see your provider, you will need to give a more detailed description of your medical history and current symptoms. You will also need to provide a list of medications that you currently take—including any supplements and vitamins.
During your visit, a medical provider will examine you and may order diagnostic testing if needed. Depending on your condition, you may be prescribed medication (such as antibiotics) or you may be referred to a specialist for further treatment. The length of your visit will depend on the severity of your condition and the type of treatment you require.
Recap: Going to Urgent Care With Insurance
There are some key things to remember when you are going to urgent care as an insured person.
- First, you should be aware of which urgent care clinics accept your insurance, and what your copays and deductibles are.
- Come prepared to pay your copay or the total cost of your visit if your urgent care doesn’t accept your insurance or if your deductible isn’t met.
- Bring your insurance card and identification card with you when you go to urgent care.
Now all you need to do is find urgent care clinics near you! We can help—start your search with Solv.
Frequently asked questions
Does insurance cover urgent care visits?Yes, most insurance plans do offer coverage for urgent care visits. However, the coverage will depend on your specific plan and the urgent care you visit.
What are premiums, copays, and deductibles in health insurance?A premium is the monthly cost of staying enrolled in an insurance plan. A copay is a fixed amount that you pay for a medical service, such as an urgent care visit. A deductible is the amount you pay before your insurance starts covering costs.
What are the different types of insurance coverage?Different types of insurance coverage include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point of Service Plan (POS), Medicare, Medicaid, High Deductible Health Plan (HDHP), and Exclusive Provider Organization (EPO).
How do urgent care clinics work with insurance companies?Each insurance provider determines if it covers urgent care centers or not. In many cases, insurance providers will cover urgent care, but patients will be expected to pay a co-payment or co-insurance.
Is urgent care more expensive than the emergency room?No, in general, emergency room visits are more expensive than urgent care visits because emergency rooms are equipped to handle severe medical emergencies and thus, they have more advanced medical equipment and resources available.
Can I go to urgent care with out-of-state insurance?Yes, some insurance plans cover services in other states. However, you should check with your insurance provider before you go. They can explain your out-of-state coverage and even help you find providers who are along your route or at your destination that accept your insurance.
What happens if I go to urgent care without my insurance card?If you find yourself going to urgent care without your insurance card, you can check for your insurance information by logging into your online portal through your insurance’s website. If you are unable to find your information through an online portal, you can call your insurance provider and get the information from them over the phone.
Can urgent care deny treatment for non-payment?Yes, some urgent care clinics can turn you away if you are unable to pay. However, most urgent care clinics accept cash or credit cards. Some clinics may also offer payment plans or financial assistance programs for patients who can't afford to pay their bills in full.
Solv has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references.
- Insurance Coverage: Major Types and How They Work. (July 23, 2023) https://www.investopedia.com/terms/i/insurance-coverage.asp
- Understanding HMO, PPO, HDHP, POD, and EPO. (July 23, 2023) https://www.insurance.com/health-insurance/difference-between-ppo-hmo-hdhp-pos-epo.html
- Medicare and Medicaid. (July 23, 2023) https://www.hhs.gov/answers/medicare-and-medicaid/index.html
- Urgent Care vs. Emergency Care Costs. (July 23, 2023) https://www.debt.org/medical/emergency-room-urgent-care-costs/
- Urgent Care: The evolution of a Revolution. (July 23, 2023) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3817457/
- EMTALA. (July 23, 2023) https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/emtala.pdf