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Is Urgent Care Covered with Insurance?

Many patients waiting in an emergency room for healthcare, blurred image - health insurance and urgent care

In most cases, yes. When you or a family member gets sick or injured, it can be hard to decide if you should try to make an appointment with your primary care physician (PCP), go to urgent care, wait in line at the emergency room or just try over-the-counter medications and lots of water and sleep.

If your child has a bad sore throat, it could be strep throat. That’s a medical issue needing treatment and prescribed antibiotics from a doctor or nurse practitioners. If you’ve got a high fever and are experiencing other sudden onset symptoms that last longer than 24 hours, you may want a medical opinion.

Your primary care provider may be too booked up to see you anytime soon. In that situation, you have several options, including visiting an urgent care center or a hospital emergency room. Many people also have the choice of using an e-medical service, such as Teledoc.

However, all of these choices come with varying price tags. So, which one is going to be the quickest and least painful on your bank balance? If you have health insurance, you may be surprised at the answer.

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

Typically, an urgent care facility is going to be able to see you quicker and will cost less than an ER visit. Most walk-in clinics allow you to make an appointment online, so you can wait at home instead of in a place full of other sick people. Urgent care is a good idea for minor illnesses and injuries.

In the ER, you’ll need to wait to be seen until those with more critical illnesses and injuries are processed. However, when the situation is a true emergency, such as chest pains or a serious injury, an emergency room is the best option. If you go to an urgent care clinic with a life-threatening emergency, the staff there will likely send you to an ER.

How Much Does an Urgent Care Visit Cost?

The cost to go to an urgent care facility averages about $150. Of course, this depends on the severity of the medical issue and the complexity of the care.

If you have health insurance, you should have some coverage for a visit to a walk-in clinic. During Open Enrollment, you can change your plans and options to make sure you have a clear understanding of what your plan covers and how much you will be responsible for if you need an urgent care service.

Senior woman is smiling as she examines medical bill from urgent care - health insurance

Understanding Insurance Coverage

Choosing the right type of health insurance can be confusing. Healthcare plans are generally open for enrollment and changes during Open Enrollment, which happens anywhere from October through January, depending on where you live and which provider you choose.

Medicaid is open for enrollment all year, however.

Private Health Insurance

Private health insurance is a health coverage plan between an individual or family and an insurance provider, rather than the government. This includes employer-sponsored plans, which about half of Americans use. You can also purchase private healthcare through the health insurance marketplace established under the Affordable Care Act. In many cases, these plans are subsidized by the government.

Most private insurance health plans offer some help with urgent care visits, as well as hospital ER visits. You may have to meet a deductible before your health insurance kicks in and pays a percentage. Some plans offer the ability to visit a walk-in clinic without paying the deductible.

It’s always best to check with your plan’s care specialists for comprehensive information.

Medicare and Medicaid

Medicare and Medicaid are government-sponsored programs for certain demographics. Medicare is for people aged 65 and older and Medicaid is an assistance program for those who meet certain income levels. Many states have their own cost-assistance programs for low-income residents. For example, California has Medi-Cal.

For those with Medicare, the plan’s Part B covers outpatient care.

Uninsured Individuals

Unfortunately, roughly 27.6 million people in the United States did not have health insurance in 2022. There are many reasons for this, including the cost. However, under the Emergency Medical Treatment and Labor Act, anyone who goes to an emergency room for treatment must be treated, regardless of whether they have insurance or not.

Urgent care facilities are usually willing to work with patients who come in without insurance. You may be offered a bill based on a sliding scale or the option to pay over time. There are also low-cost and free clinics in most cities who will treat anyone who walks in the door.

Remember, all patients have the right to treatment without regard for national origin, sexual orientation, gender identity or marital status. 

Deep Dive into the Details 

For those who do have health insurance, it’s important to understand how your policy works and how much you will need to pay for certain items. Most insurance plans will cover urgent care visits, but it’s vital to understand your plan’s specifics, as well as making sure your nearest urgent care accepts your insurance.

In-Network vs. Out-of-Network Providers

Most private plans want their members to visit care centers that participate in an agreement about costs. These providers are considered in-network because they’ve reached an understanding with your health insurer concerning how much they will charge for certain services and how much they will accept from the insurer in payment. When you visit an in-network provider, your insurance will either help you cover the cost or will apply the amount to your deductible.

Out-of-network providers, on the other hand, do not have an agreement with your plan. Your health plan may not cover any of the cost associated with a visit to such a facility or they may cover some, but not as much as when you choose to use an in-network medical service.

Copayments and Deductibles

Both of these terms cover the amounts you can expect to pay when using your insurance, but they are different.

In most cases, a deductible is a fixed annual amount you must pay before your health insurance kicks in to help cover the costs. A co-pay, on the other hand, is a set amount that you pay for certain services, regardless of whether your deductible has been met.

For example, if your deductible is $3,000 per year, you must pay out this amount before your insurer kicks in and starts paying. However, a co-pay may be $35 to visit your primary care doctor’s office, and that amount does not change based on meeting your deductible.


After the deductible amount is met, you will be responsible for a co-pay on services, generally consisting of a percentage, such as an 80-20 split where your insurer pays 80% and you pay 20%.

Prior Authorization

Some insurance companies require prior authorization before certain medical care will be paid for, even if they are included with your policy.  For example, some insurance companies want to give prior approval before you go to for an emergency room visit.

This typically involves calling your insurer’s phone number on your insurance card. However, if you are experiencing a life-or-death situation, don’t wait to call your insurer. Go to the nearest emergency room immediately. In most situations, the hospital will take the lead in contacting your insurer for you.

Man gets health care from a doctor at an urgent care clinic - health insurance

Tips to Ensure Urgent Care Coverage

When you are sick or injured and need help, you cannot always wait for the next available appointment with your main doctor. A walk-in clinic is a great option to get some help fast. But you also want to make sure you won’t be saddled with a huge bill. Here are some tips to help navigate urgent care coverage.

1. Understand the benefits and limitations of your insurance policy and pick a clinic that accepts your plan. Call your insurance provider and ask what your costs may be before you go. In most cases, it will be cheaper than the emergency room and comparable to visiting your doctor’s office.

2. The staff at the urgent care won’t have your medical history at their fingertips, like your primary care physician (PCP). Bring a list of all your medications, as well as any history of chronic conditions, surgeries and allergies.

3. Most people can find immediate care at a clinic anytime day or night. You probably won’t have to wait very long to see someone and it’s cheaper than the ER. However, there are peak times to avoid, such as early morning and during lunch. Many facilities offer the ability to check in online (as well as get other valuable information) so you can cut your wait time down even further.

Use of Telemedicine for Urgent Care

Many health insurance providers now offer a more recent option: telehealth. In fact, some of them would rather you try that option first. With telemedicine, you may be able to connect with your PCP in a face-to-face visit over the phone or computer. Alternatively, you may connect with a medical professional supplied by your plan.

The beauty of this is you don’t need to leave your home, and, in some cases, it can be the cheapest option of all. A teledoc can generally issue prescription medications for you, as well as help you understand how to take care of yourself while you are ill. Some common conditions that work well with telehealth include:

  • COVID, colds and flu
  • Minor cuts, abrasions
  • Urinary tract infections
  • Minor sprains
  • Digestive issues

Your telehealth professional will help you decide if you need to go to an in-person appointment.

Make Informed Decisions about Insurance with Freeway Insurance

At Freeway Insurance, we can help you navigate the sometimes-confusing maze of picking the right health insurance plan for you and your family, as well as other options that may be available for you. Our agents are professional, caring and bilingual. Give us a call today at (800) 777-5620 to let us help you find the perfect health care, check us out online or just stop by one of our locations for a chat.

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