Urgent & Emergency Care
Knowing the difference between urgent care and a medical emergency can save you time and money.
Urgent care situations include moderate fever, sore throat or sprains. This is not a complete list of urgent care situations. For these and other common medical conditions, call your PCP or visit an urgent care center.
Medical emergencies include:
- Heart attacks and strokes
- Poisoning
- Loss of consciousness
- Severe burns
- Obvious bone fractures
- Wounds requiring stitches
This is not a complete list of emergency situations. For these and other serious or life-threatening conditions, seek immediate treatment by going to the nearest ER or calling 911.
Urgent Care
You may experience an urgent medical condition – one that can’t wait for a normal appointment but is not a true medical emergency, either.
Your urgent care options:
- Your PCP: Call your PCP first, if you are able to. Your PCP may tell you how to treat the condition yourself, send you to the nearest urgent care center or make an appointment to see you as soon as possible.
- Our 24/7 Nurse Line: The registered nurses staffing our 24/7 Nurse Line are always available to answer your medical questions and help you determine if a condition is urgent or a true medical emergency.
- Horizon CareOnline℠: Eligible members can talk with a U.S. board- certified, licensed doctor via video or phone, 24 hours a day. seven days a week – no appointment needed.
- Urgent care center: An urgent care center is a good alternative when you need care right away and you can’t get to your PCP’s office. You’ll probably have a much shorter wait for non-critical care than at an Emergency Room (ER) and your out-of-pocket costs may be less.
Emergency Care
In general, an emergency is defined as a medical condition of such severity that a prudent layperson with average knowledge of health and medicine would seek immediate medical attention.
If you reasonably believe that a condition is a medical emergency:
- Go directly to the nearest ER, or call 911.
- Call your PCP. In some situations, you may be able to call your PCP before you go to the ER. If you can’t, call as soon as reasonably possible, or ask a family member or friend to call. It is important that your PCP be kept aware of your condition. Without this information, your PCP cannot coordinate your care.
You do not need to call Member Services to notify us of a medical emergency, unless you are admitted to the hospital.
Medical Emergency Screening Exam
Sometimes, you may not be sure if your condition requires emergency care. Your plan covers a medical emergency screening exam, which is an evaluation performed in a hospital ER by qualified health care personnel, to determine if a medical emergency exists. We’ll cover the cost of the medical emergency screening exam. If the exam determines that an emergency does not exist, please follow up with your PCP. If you continue to receive care at the ER after you have been advised that your condition is not a medical emergency, you will have to pay the total cost for any non-emergency-related services you receive.
ER Copays
Even if your PCP refers you to the ER, you’ll have an ER copay and you may also be responsible for a coinsurance amount. But if you’re admitted to the hospital as an inpatient within 24 hours, we’ll waive the ER copay.
Follow-up Care after an ER Visit
When you are discharged from the ER, contact your PCP, who should coordinate all medical emergency follow-up care. You do not need to call Member Services after you visit the ER.
Out-of-Network Coverage
Your Horizon HMO Access plan does not include out-of-network coverage for non-emergency services.
You must use in-network hospitals for care, unless you have a medical emergency. In an emergency, call 911 or go to the nearest ER without worrying about network status.
