Insurance Agent Forum

[Bob_The_Insurance_Guy]

OK, folks.

Who wants to give me a clear cut answer as to the difference between Emergency Care and Urgent Care. I know, by reading through the Explanation Of Benefits for each Medicare Advantage Plan, that they are different, but I don't know how to deliniate one from the other.

Is it that one is in the service area, and the other is not?



I know that Emergency Care has Worldwide Coverage, and Urgent Care does not, but other than that, what is the difference?

[somarco]

Are you looking for a general response or something specific to Medicare & MA plans?

[Bob_The_Insurance_Guy]

In regards to the Medicare Advantage Plans.

[johnrocks]

Emergency rooms are attached to a hospital Urgent care units are not. They are the clinics that you see popping up that mainly take care of the non-emergcey things on nights and weekends like the stomach flus, bad tooth aches etc.

[Cenla Agent]

Urgent Care is basically going to a Dr. outside of the plan's service area for something that is "urgent" i.e. not forseeable. On some plans there may be a flat copay regardless of what facility or type of dr. it is. On others you will pay the PCP or specialist copay, and there may be a different copay if it is at an urgent care or immediate care facility. So the bottom line is that Urgent Care is not limited to a so called urgent care facility.

[Cenla Agent]

The definition of Urgent Care is much more of a factor with HMO and PPO plans. It really doesn't matter as much with PFFS since coverage is not limited by service area with that plan. The main thing with PFFS is pointing out if there is a different copay than with a regular office visit. Some plans are more expensive for this, some are not.

But imagine a scenario with a prospective HMO client. He's on coumadin and needs the blood tests every few months. He travels to the opposite end of the country for the entire summer. Such an individual is not a good fit for an HMO since the required coumadin check is forseeable and will not be covered by the HMO outside of his service area because it does not qualify as urgent care.

[johnrocks]

urgent_care_definition.pdf

[arnguy]

In PA, Independence Blue Cross HMO (Keystone) allows members to temporarily transfer coverage to another area through a BX in that area. A lot of snowbirds go to FL for the winter months and transfer their coverage during that period.