Understanding Your Health Insurance

Co-pay? Deductible? Co-insurance? Health insurance and paying for medical care can be confusing for some of us. Use this quick guide to help you understand when and how much you may end-up paying for your care visit.*


Uninsured? If You Are Paying Cash or Won’t Be Using Health Insurance

If you don’t have, or are planning not to use, health insurance during your visit we offer reasonable self-pay rates reflecting a discount for prompt payment. Based on your stated reason for coming in to see us, we can provide an estimate for the cost of your visit during check-in. After you meet with your healthcare provider, depending on the scope of care and services provided, the final cost of your visit may be different than the initial estimate.

If Your Insurance Includes a Co-Pay

What is it? Your co-pay is the fixed amount that you pay for medical care and is usually collected at the time you receive your medical services. Your office visit  co-pay amount may be different than the amount you would pay for an urgent care or ER visit.

Some insurance carriers may have preferred provider's that they want you to use. If this is the case, the amount of your  co-pay may differ depending on where you go - even if there is a specific  co-pay amount printed on your insurance ID card. Please contact us and or your insurance company to verify network status.

If Your Insurance Includes a Deductible

What is it? Many plans include a deductible - this is the amount you must  pay out-of-pocket for health care BEFORE your health insurance coverage kicks in and begins to pay. Deductibles are usually set at rounded amounts (such as $500 or $1,000).With the deductible you pay 100% of your medical care until your deductible amount is met. After that, you and your insurance share in the cost of care. If you have a plan with a high deductible then you will have cheaper monthly rates for your insurance, but you will likely pay more up front when you need care. Some plans may cover the full amount of certain medical services before your deductible is met.

If Your Plan Includes Co-Insurance

What is it? Co-insurance is the amount of money you pay for your health services, and begins AFTER your deductible has been met. Your co-insurance percentage is the amount that you will be responsible to pay for your care. The remainder is what your insurance plan pays. For some, you may have both a co-pay and co-insurance. Coinsurance is usually a predetermined percentage of the total bill. For example: If the policy’s co-insurance is set at 15% and the bill comes to $100, the policy-holder owes $15 in co-insurance.

After Hours Visits

If you visit after standard business hours (after 5pm on weekdays, or on weekends and holidays), the cost of your care will include a $25 After Hours Visit fee. Some insurance plans cover this fee. If your insurance plan does not cover some or all of this amount it will be added to your amount due.

How the Amount You Owe is Determined

During your visit we make an effort to reach out to your insurance carrier to verify your benefits. We use this verification to estimate the amount you will need to pay and how much your insurance will cover. At the end of your visit we will collect the amount you owe. Your amount owed may include a deductible or co-insurance based on the information your insurance carrier provides to us even if you paid a co-pay or a deductible amount.

Next, we will file a claim with your insurance provider after your visit. We will send you a statement for any remaining balance due based on the amount paid by your insurance, or promptly process a refund if applicable. If your insurance provider denies part or all of your claim, then you will be billed for the remaining or full amount of your visit.

*Contact your insurance provider if you have questions or need to verify coverage in advance of your visit. They can provide answers and offer more information regarding your personal coverage, deductibles, co-insurance or co-pays.

Reference

"Understanding Health Insurance" 2018. https://www.medicalbillingandcoding.org/health-insurance-guide/overview/