Do you know your insurance?
A copay is a fixed amount for a covered service, paid by you to the healthcare provider before receiving the service.
This is the percentage of costs of a covered healthcare service that you pay after you have paid your deductible. For example, you have 20% coinsurance. For a $100 visit, you pay $20 and your insurance pays $80.
This is the amount that you pay for covered healthcare services before your insurance plan starts to pay.
If your office visit costs $125 and you have not met your $1500 deductible, then you pay $125.
Out-of-pocket maximum is the most that you will have to pay for covered medical services each year. Copay, deductible, and coinsurances contribute to your out-of-pocket maximum. Once you have reached your yearly limit, your insurance generally pays 100% of the covered medical expenses.
Insurance ID card
John has C.C. Health Insurance. He has an appointment with his primary care physician, Dr. Chung, because his allergies are acting up. Based on his insurance card, how much does he have to pay before seeing Dr. Chung?
Ans. A. Based on his insurance card, he needs to pay $5 as a copay for a PCP.
Dr. Chung is in-network with C.C. Health Insurance. He charges $200 for an office visit. John’s insurance processed the claim, and he received the explanation of benefits (EOB) that showed he is responsible for coinsurance. How much is the bill that John received?
A. $ 10
B. $ 40
Ans. B. For an in-network provider, John has 20% coinsurance. 20% of $200 is $40. Thus, he paid $40 as coinsurance while C.C. Health Insurance paid $160 (80% of $200) to Dr. Chung.