Urgent Care, ER, or Telehealth: Where to Go

When you or your child gets sick or hurt, you have to decide fast: the emergency room, an urgent care clinic, your regular doctor, or a video visit? The right choice depends on how serious it is. It can also change what you pay. Here's a plain-language guide, plus a short checklist to do before you need it.

If you think it's an emergency, call 911 or go to the nearest emergency room. Don't stop to check your insurance first. This guide is not medical advice.

Your main options

MedlinePlus (from the National Library of Medicine) lists these choices when you have an unexpected illness or injury:

• Call a nurse advice line offered by your health plan or employer
• Call your regular doctor or provider
• Go to an urgent care clinic
• Go to an emergency department (ER) right away

Telehealth is another option many plans offer (more below).

When to call 911 or go to the ER

MedlinePlus says if a person or unborn baby could die or be permanently disabled, it is an emergency.

Call 911 (or your local emergency number) to have help come to you right away for things like:

• Choking or stopped breathing
• Head injury with passing out, fainting, or confusion
• Neck or spine injury, especially with loss of feeling or trouble moving
• Severe chest pain or pressure
• Severe shortness of breath
• Severe burn, electric shock, or lightning strike
• A seizure that lasted more than 1 minute, or the person doesn't wake up quickly
• Suddenly not able to speak, see, walk, or move
• Sudden weakness or drooping on one side of the body

Go to the ER or call 911 for problems such as trouble breathing, fainting, pain in the arm or jaw, a sudden or unusually bad headache, sudden confusion, heavy bleeding, a possible broken bone (especially if bone is pushing through the skin), a deep wound, coughing or throwing up blood, severe pain, a severe allergic reaction with trouble breathing, poisoning or overdose, or seizures. MedlinePlus has the full list (see Sources).

Mental health crisis: MedlinePlus says if you are thinking about hurting yourself or others, call or text 988 or chat at 988lifeline.org. You can also call 911 or go to the ER. Don't delay.

When urgent care may fit

MedlinePlus says urgent care is for problems that are not life threatening or risking disability, when you're worried and can't see your own provider soon enough. Examples it lists:

• Common mild illnesses: colds, flu, earaches, sore throats, migraines, low-grade fevers, and limited rashes
• Minor injuries: sprains, back pain, minor cuts and burns, minor broken bones, or minor eye injuries

Don't wait too long to get care.

Not sure? Call first

If it isn't one of the serious problems above and you're not sure what to do, MedlinePlus suggests calling your provider. After hours, your call may go to an on-call nurse or provider. Your plan may also have a nurse advice line. The number is often on your plan's website or ID card. Ask your plan.

Telehealth basics

The U.S. Department of Health and Human Services (HHS) says telehealth (sometimes called telemedicine) lets you see your provider without going to their office, using a phone, computer, or tablet. You can:

• Talk with a provider by phone or video
• Send secure messages to your provider
• Share health readings, like blood pressure

HHS says telehealth can save travel time, may get you an appointment faster, and can give you more choices. It also says telehealth isn't right for everyone or every condition, and sometimes you'll need to be seen in person.

Coverage varies. Before you use telehealth, ask your plan:

• Does my plan cover telehealth visits? Which kinds (video, phone, messages)?
• Is there a specific telehealth service that's in-network?
• What will I pay for a telehealth visit compared to an office visit?

How costs can differ by setting

What you pay can change a lot depending on where you go. Your plan may charge a copay (a flat amount), coinsurance (a percentage), or make you pay toward your deductible first. Each setting can have different rules. (See Health Insurance Terms: Deductible, Copay, and More.)

• MedlinePlus says treatment in an ER can cost 2 to 3 times or more than the same care in your provider's office, and your plan may charge a higher copay for the ER.
• Your Summary of Benefits and Coverage (SBC) lists what you pay for common care, often including the emergency room, urgent care, and office visits. Check your plan summary. (See How to Read Your Summary of Benefits and Coverage.)
• Stay in-network for urgent care and telehealth when you can. Out-of-network costs are usually higher, and some plans (like many HMOs) may not cover non-emergency out-of-network care at all. (See HMO vs PPO vs HDHP: How to Choose a Health Plan.) Ask your plan.

Your rights in an emergency

HealthCare.gov says:

• In an emergency, get care from the closest hospital that can help you. That hospital will treat you whether or not you have insurance.
• In a true emergency, go straight to the hospital. Insurers can't require prior approval for emergency room services from a provider or hospital outside your plan's network.
• Insurers can't make you pay more in copays or coinsurance for emergency care at an out-of-network hospital.
• You may still pay something. It depends on your plan and the hospital. For example, ER care may count toward your deductible.

The No Surprises Act adds protection from many surprise out-of-network bills after emergency care. Ground ambulances generally aren't covered by it. (See Surprise Medical Bills and Your Rights.)

Before you need it: a quick checklist

MedlinePlus suggests learning your choices before you have a problem. Take 15 minutes now:

• Save phone numbers in your phone: your doctor, the closest ER, your plan's nurse line, an in-network urgent care clinic, and a walk-in clinic.
• Find in-network urgent care near home and work using your plan's provider search.
• Check telehealth: does your plan cover it, and which service is in-network?
• Look up your costs for the ER, urgent care, telehealth, and office visits in your SBC.
• Keep your insurance card (or a photo of it) with you.
• Do the same for family members on your plan, especially kids away at school.

Questions to ask your plan

• What do I pay for an ER visit, urgent care, a telehealth visit, and an office visit?
• Do any of those apply to my deductible first?
• Is there a nurse advice line? What's the number and hours?
• Which urgent care clinics and telehealth services are in-network?
• Do I need a referral for urgent care? (Some HMOs have rules. Ask your plan.)

Quick tips

• Emergency? Call 911. Don't check coverage first.
• Not an emergency? Your doctor, a nurse line, telehealth, or urgent care may fit.
• Stay in-network for non-emergency care when you can.
• Know your costs before you need care. Check your SBC.