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Health Insurance Basics: Urgent Care Centers Versus Emergency Room Care

In an ideal world, when you are sick or injured, you can go to your primary care doctor for treatment. However, that is not always possible. You may need more immediate care, or your problem might be more severe and require X-Rays or other diagnostic tests. Sometimes, you may need help when your doctor's office is closed. In those cases, it's time to head to an urgent care center or emergency room.

Urgent Care Versus ER

Call Your Doctor First

Many primary care doctors recommend calling their office first, so the on-call physician or nurse can tell you what to do.

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Urgent Care Center Versus the Emergency Room

It is important to know the difference between an urgent care center and an emergency room and how your health insurance plan can affect where you go. An urgent care center is open longer hours and often on the weekends. It is staffed by doctors who can assess and treat non-life-threatening problems when there is no obvious need for hospitalization, according to the American Academy of Urgent Care Medicine.

An emergency room is part of a hospital. When you go there for treatment, you'll join a mixture of people with ailments that can range from a sprained thumb to a heart attack. Staff members assess the cases that come in, determine how urgent each medical issue is and decide the order in which you'll be seen. On calm days, you may see a doctor right away, but you can often wait hours.

Many primary care doctors recommend calling their office first, so the on-call physician or nurse can tell you what to do.

In-Network or Out-of-Network?

You should also know what your plan covers if you're going for treatment outside of your primary care office. Some plans pay different amounts of the bill depending on whether the doctor or medical facility is in-network or out-of-network. If the doctor or facility is in-network, they have a contract with the insurance company for the plan that you're enrolled in. The health plan pays more of the bill, leaving you with fewer out-of-pocket costs. With some health plans, you may only be responsible for the copay fee for in-network care.

If you see an out-of-network provider, the health plan pays a lower percentage of the cost, and you are responsible for the remainder, known as "balance billing." For out-of-network care, you may sometimes have to pay the medical bill yourself and your insurance company will send you a reimbursement check for the amount it will cover.

If you need care outside of your doctor's office hours or your problem is severe enough to need a higher level of care, it's a good idea to first call the urgent care clinic or hospital to find out whether they accept your health insurance plan – be sure to tell them which network you are enrolled in. That information is shown on your BlueCross ID Card. Going to an in-network facility will cost you less.

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