Medicare Urgent Care Copay

Posted : admin On 12/14/2021

Veterans may be charged a copayment for urgent care that is different from other VA medical copayments. Copayments depend on the Veteran’s assigned priority group and the number of times an urgent care provider is visited in a calendar year. Copayment charges are billed separately by VA as part of VA’s billing process. You pay a Copayment for each emergency department visit and a copayment for each hospital service. You also pay 20% of the Medicare-approved amount for your doctor's services, and the Part B Deductible glossary applies. If your doctor admits you to the same hospital for a related condition within 3 days of your emergency department visit, you don't pay the copayment because your visit is.

Urgent care centers are becoming increasingly popular acrossthe country, as they’re often convenient and have short wait times.Fortunately, Medicare has coverage for many services at urgent care centers.

What Do I Need to Know About Medicare Urgent Care Coverage?

Urgently needed care. Urgently needed care. Medicare Part B (Medical Insurance) covers urgently needed care to treat a sudden illness or injury that isn’t a medical emergency requiring immediate medical attention to prevent a disability or death. Your costs in Original Medicare. The maximum copayment that Medicaid may charge is based on what the state pays for that service, as described in the following table. These amounts are updated annually to account for increasing medical care costs. FY 2013 Maximum Nominal Deductible and Managed Care Copayment Amounts. Deductible $2.65; Managed Care Copayment $4.00. Urgent Care Center $35 copay. $30 copay per evaluation; up to 2 per year. 1 Under Basic Option you pay 30% of our allowance for agents, drugs and/or supplies you receive during your care. 2 If you have Medicare Part B primary, your costs for prescription drugs may be lower.

Just like with any other healthcare provider, you need to make sure that the urgent care center accepts Medicare before you go, or you risk paying for the costs yourself. You can determine if the urgent care center, or any other provider, accepts Medicare simply by calling them and asking. If you need to locate a center that accepts Medicare, you can use Medicare’s online tool. It’s always wise to confirm that the provider accepts Medicare before your visit, in case they’ve made recent changes that haven’t been reflected online yet.

If you’re traveling, we recommend that you make a note ofthe urgent care centers available near your destination. You could also bookmarkMedicare’s tool for easy retrieval should you need it.

What Does Medicare Pay for Urgent Care Visits?

Urgent care is primarily covered under Medicare Part B. Thismeans that whatever you currently pay to see the doctor will most likely bewhat you have to pay at an urgent care facility. Your costs can vary based onthe type of coverage you have:

  • Original Medicare: If you only have Original Medicare (Medicare Part A and Part B), you’ll most likely need to pay for 20% of your visit, as well as any applicable deductibles and copays. There’s no cap on the 20% coinsurance for services that Medicare covers, so your total out-of-pocket cost will depend on what your bill is.
  • Medicare Supplement Plans: You can use your Medicare Supplement plan anywhere that accepts Medicare. Medicare Supplement plans will pay their portion as long as Medicare pays first. For instance, if you have Medicare Supplement Plan F and Medicare pays its portion for each service, you shouldn’t have any out-of-pocket costs. If you have Medicare Supplement Plan N, which doesn’t cover copayments, you may be required to pay the Medicare urgent care copay of up to $20 up front.
  • Medicare Advantage Plans: Medicare Advantage plans are a form of private insurance and are primary instead of Medicare. If you have an Advantage plan you should review your policy for details on networks, costs, and coverage.

Medicare Urgent Care Copay Card

What Urgent Care Services are Covered by Medicare?

Any of the approved services that you would receive by yourdoctor should also be covered at an urgent care center. These services include,but aren’t limited to:

  • Annual physicals
  • Some vaccinations
  • Treatment for non-life-threatening illness
  • Lab work

What Happens If I Use an Urgent Care Center That Doesn’t Accept Medicare?

If you receive treatment at an urgent care center that doesn’t accept Medicare, you’ll most likely have to pay the entire cost out-of-pocket. Medicare may reimburse you if your treatment was an emergency, but it’s best to avoid taking a financial risk by choosing a center that accepts Medicare.

Overall, urgent care centers can be convenient when you needminor injuries or illnesses treated. In order to make sure that your servicesare covered, you need to seek treatment at a center that accepts Medicare. Otherwise,you risk paying for the entire cost yourself. A Medicare Supplement plan canhelp cover the Medicare coinsurance and copays, but if you have a MedicareAdvantage, plan your network, coverage, and costs may vary.

Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

This online publication has been updated to include the Amendments through January 1, 2014. For details such as the effective dates of amendments, see your group-specific amendments in the Publications & Forms section of this site.

Here's a guide to your copayments for services covered under The Empire Plan. See your Empire Plan Certificates for details.


Services by Empire Plan Participating Providers


You pay only your copayment when you choose Empire Plan Participating Providers for covered services. Check your directory for Participating Providers in your geographic area, or ask your provider. For Empire Plan Participating Providers in other areas and to check a provider's current status, call The Empire Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose UnitedHealthcare or use the online Participating Provider Directory.

Office Visit: $20 Copayment

Office Surgery: $20 Copayment
(If there are both an Office Visit charge and an Office Surgery charge by a Participating Provider in a single visit, only one copayment will apply, in addition to any copayment due for Radiology/Laboratory Tests.)

Radiology, Single or Series; Diagnostic Laboratory Tests: $20 Copayment
(If Outpatient Radiology and Outpatient Diagnostic Laboratory Tests are charged by a Participating Provider during a single visit, only one copayment will apply, in addition to any copayment due for Office Visit/Office Surgery.)

Routine Mammography Screening: $20 Copayment

Adult Immunizations: $20 Copayment for Herpes Zoster (Shingles) immunization for enrollees age 55 and over but under age 60. Paid in full benefit for adult immunizations as recommended by the Advisory Committee on Immunization Practices of the Center of Disease Control and Prevention when received from a participating provider.

Allergen Immunotherapy: No Copayment

Well-Child Office Visit, including Routine Pediatric Immunizations: No Copayment

Prenatal Visits and Six-Week Check-Up after Delivery: No Copayment

Chemotherapy, Radiation Therapy, Dialysis: No Copayment

Authorized care at Infertility Center of Excellence: No Copayment

Medicare Urgent Care Copay

Hospital-based Cardiac Rehabilitation Center: No Copayment

Free-standing Cardiac Rehabilitation Center Visit: $20 Copayment

Urgent Care Center: $20 Copayment

Contraceptive Drugs and Devices when dispensed in a doctor's office: $20 Copayment*
(in addition to any copayment(s) due for Office Visit/Office Surgery and Radiology/Laboratory Tests)

*Copayment waived for preventive services under the federal Patient Protection and Affordable Care Act (PPACA). See NYSHIP Online for details. Diagnostic services require Plan copayment or coinsurance.

Outpatient Surgical Locations (including Anesthesiology and same-day pre-operative testing done at the center): $30 Copayment

Medically appropriate local commercial ambulance transportation: $35 Charge

Chiropractic Treatment or Physical Therapy Services by Managed Physical Network (MPN) Providers

You pay only your copayment when you choose MPN network providers for covered services. To find an MPN network provider, ask the provider directly, or call UnitedHealthcare at 1-877-7-NYSHIP (1-877-769-7447) toll free. Internet:

Office Visit: $20 Copayment

Radiology; Diagnostic Laboratory Tests: $20 Copayment
(If Radiology and Laboratory Tests are charged by an MPN network provider during a single visit, only one copayment will apply, in addition to any copayment due for Office Visit.)

Hospital Outpatient Department Services

Emergency Care: $70 Copayment
(The hospital outpatient copayment covers use of the facility for Emergency Room Care, including services of the attending emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electrocardiogram and pathology services.)

Surgery: $60 Copayment*

Diagnostic Laboratory Tests: $40 Copayment*

Diagnostic Radiology (including mammography, according to guidelines): $40 Copayment*

Administration of Desferal for Cooley's Anemia: $40 Copayment*

Physical Therapy (following related surgery or hospitalization): $20 Copayment

Chemotherapy, Radiation Therapy, Dialysis: No Copayment

Pre-Admission Testing/Pre-Surgical Testing prior to inpatient admission: No Copayment

*Only one copayment ($60 copayment if surgery is included; $40 is diagnostic outpatient services only) per visit will apply for all covered hospital outpatient services rendered during that visit. The copayment covers the outpatient facility. Provider services may be billed separately. You will not have to pay the facility copayment if you are treated in the outpatient department of a hospital and it becomes necessary for the hospital to admit you, at that time, as an inpatient.

Be sure to follow Benefits Management Program requirements for hospital admissions, skilled nursing facility admission and Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine tests.

The Empire Plan Mental Health and Substance Abuse Services by Network Providers When You Are Referred by Beacon Health Options

Call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) toll-free before beginning treatment.

Visit to Outpatient Substance Abuse Treatment Program: $20 Copayment

Visit to Mental Health Professional: $20 Copayment

Emergency Room Care: $70 Copayment

Psychiatric Second Opinion when Pre-Certified: No Copayment

Mental Health Crisis Intervention (three visits): No Copayment

Inpatient: No Copayment

Empire Plan Prescription Drugs*

Note: Medicare-primary enrollees or dependents should refer to the Empire Plan Medicare Rx Evidence of Coverage for prescription copayment amounts

(Only one copayment applies for up to a 90-day supply.)

Up to a 30-day supply from a network pharmacy or through the Mail Order Pharmacy or the Designated Specialty Pharmacy

Does Urgent Care Charge A Copay

$5 Copayment – Level 1 Drugs or most Generic Drugs
$25 Copayment – Level 2, Preferred Drugs or Compound Drugs
$45 Copayment – Level 3 or Non-preferred Drugs**

31 to 90-day supply from a network pharmacy

$10 Copayment –Level 1 Drugs or most Generic Drugs
$50 Copayment –Level 2, Preferred Drugs or Compound Drugs
$90 Copayment – Level 3 or Non-preferred Drugs**

Urgent Care Copay Without Insurance

31 to 90-day supply through the Mail Order Pharmacy or the Designated Specialty Pharmacy

$5 Copayment –Level 1 Drugs or most Generic Drugs
$50 Copayment –Level 2, Preferred Drugs or Compound Drugs
$90 Copayment – Level 3 or Non-preferred Drugs**

*Note: Oral chemotherapy drugs for the treatment of cancer do not require a copayment. In addition, generic oral contraceptive drugs and devices or brand-name drugs/devices without a generic equivalent (single-source brand-name drugs/devices) do not require a copayment.

**If you choose to purchase a brand-name drug that has a generic equivalent, you will pay the non-preferred drug copayment plus the difference in cost between the brand-name drug and its generic equivalent (with some exceptions), not to exceed the full retail cost of the covered drug.

***Covered services defined as preventive under the Patient Protection and Affordable Care Act are not subject to copayment.