VeriStat: Cost Sharing for Emergency Rooms Versus Urgent Care: Part I of III

This is the first of three posts on this subject

Emergency room visits are one of the most common interactions people have with our healthcare system, and they can be quite expensive for both individuals and their insurance companies. In recent years, urgent care clinics have emerged as a cheaper alternative to the emergency room for less severe conditions like flu and minor injuries that occur outside traditional providers’ business hours and for folks without a regular doctor.

The data science team at Vericred analyzed the benefit designs for health insurance plans on the individual and small group ACA markets to see the difference in the way the costs for emergency room and urgent care are split between individuals and their health insurance companies. The results show that for both markets and all metal levels,* insurance companies are more likely to share the cost before the deductible for urgent care than for the emergency room. This means that an individual who has not yet met her deductible might have to shoulder the full cost of an emergency room visit, while the cost for the same visit at urgent care would be shared with her health insurance company.

It’s worth checking your insurance coverage to see the difference in the way emergency room and urgent care visits are covered—it could end up saving you money if you experience an urgent medical condition when the option to see your doctor is not available.

* Platinum and catastrophic plans excluded. Catastrophic plans typically have a deductible equal to the out of pocket maximum, which removes cost-sharing variation. Platinum plans often have a $0 deductible, meaning there is no distinction between before and after the deductible.

Part I_VeriStat - ER vs UrgentCare-2

*Updated 10/17/2018

This is the first of three posts; in the next post, we will look more deeply at the difference in the way that cost sharing for emergency room and urgent care visits are structured.