Common insurance terminology: 1. Co-pay: A set amount you pay for a service (e.g. $10 exam copay) You only pay for copay for a certain procedure REGARDLESS if you have met your deductible.
2. Co-insurance: A percentage you pay for a service or material benefit (e.g. 30% co-insurance). Co-insurance can be 0% to 90%. Co-insurances only applicable ONLY after you meet your deductible and before you meet you maximum OOP. If you have not met your deductible, you pay contract price (price negotiated between insurance company and providers–typically lower than your private pay price)
3. Deductible: The amount you are responsible for before your insurance “kicks in.” Co-insurance and deductibles go hand in hand. Copays and deductibles are independent. There is an individual deductible and a family deductible. Deductibles can range from $0 to $10K+, depending on your plan. Once you meet your individual deductible, your insurance kicks in and you can use your coinsurance. Once your family deductible is met, everyone in the family does not have to meet their individual deductible and they can use their coinsurance. 4. Maximum Out of Pocket/OOP/Stop Loss: Maximum amount you are responsible for during the year you are covered under your insurance before your insurance covers everything regardless of your copay or coinsurance EXAMPLE: PCP Office Visit: $10 copay Specialist OV: $25 copay Urgent Care: $50 copay ER: $100 copay Individual Deductible: $500 Family Deductible: $1000 Everything else: 20%/80% Maximum OOP: $20,000
You have the flu and need to see your family doctor. You pay $10. Family doctor refers you to allergy specialist for further testing. You pay $25. You start coughing at 7 pm and go to the urgent care: You pay $50. You can’t breathe in the middle of the night and go to the ER. You pay $100. So far, $10 + $25 + $50 + $100 = $185 gets applied to your OOP, but not your deductible. Doctor orders a chest X-ray. Contract price is $500. You have not met your deductible. You pay $500. $500 goes towards your OOP and your deductible. Afterwards, you HAVE met your $500 deducible. At this point, your coinsurance kicks in.You see your family doctor for an annual physical. You pay $10 (copays are independent of deductibles). $10 goes towards your OOP. Your doctor sees something funky and orders an MRI. Contract price is $5000. You pay $5000 X 20% = You pay $1000 for MRI. So far, $10 + $25 + $50 + $100 + $500 +$10 + $1000 = $1695 gets applied to your OOP. Your maximum OOP is $20,000. Once you pay $20,000 – $1695 (amount you paid for copays, coinsurance, and any other medical related costs) = $18,305, all of your medical care will be fully covered for the rest of the year (pay $0 copay and $0 coinsurance). Your son needs a mole removed. Contract price is $800 for surgery. You pay $800 because although you met individual deductible, you have not met the family deductible.
Keep in mind: 1. A procedure can only have a copay OR coinsurance, not both. 2. An insurance policy can have some procedures covered under different copays and some procedures covered under coinsurance. For example, under a VSP plan, the eye exam copay is $10, and the material copay is $25. There is NO coinsurance because the exam and materials are covered under copays. Under BCBS, a routine OV has a $20 copay, but an MRI is under 30% coinsurance. So, if you see your doctor for a cough, you pay $20. If you need an MRI, and the contracted price is $5000 AND you have met your deductible for the year AND you have not reached your maximum OOP, you will be responsible for $5000 X 30% = $1500.
If you have any question or concern please call us at Kudo Care Center 972-639-5836 or email us at firstname.lastname@example.org