A copayment (sometimes called “copay”) is a fixed amount you pay for a health care service, usually when you receive the service.
For example, Your plan determines what your copay is for different types of services and when you have one. You may have a copay before you’ve finished paying toward your deductible. You may also have a copay after you pay your deductible and when you owe coinsurance.
Copays can vary for different services within the same plan, like medications, lab tests, and visits to specialists. Generally, plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.
Coinsurance is your share of the costs of a health care service. It’s usually figured as a percentage of the amount we allow to be charged for services. You start paying co-insurance after you’ve paid your plan’s deductible.
For example, you’ve paid $1,500 in health care expenses and met your deductible. When you go to the doctor, instead of paying all costs, you and your plan share the cost. For example, your plan pays 70 percent. The 30 percent you pay is your coinsurance.
Generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.
A deductible is the amount you pay for health care services before your health insurance
begins to pay.
For example, if your plan’s deductible is $1,500, you’ll pay 100 percent of eligible health care expenses until the bills total $1,500. After that, you share the cost with your plan by paying coinsurance.
After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.
Out of Pocket Max
Out-of-pocket maximum/limit is the most you have to pay for covered services in a plan year..
For example, you have a plan with a $3,000 annual deductible and 20% coinsurance with a $6,350 out-of-pocket maximum. You haven’t had any medical expenses all year, but then you need surgery and a few days in the hospital. That hospital bill might be $150,000.
You will pay the first $3,000 of your hospital bill as your deductible. Then, your coinsurance kicks in. The health plan pays 80% of your covered medical expenses. You’ll be responsible for payment of 20% of those expenses until the remaining $3,350 of your annual $6,350 out-ofpocket maximum is met. Then, the plan covers 100% of your remaining eligible medical expenses for that calendar year.
Depending on your plan, the numbers will vary— but you get the idea. In this scenario, your $6,350 out-of-pocket maximum is much less than a $150,000 hospital bill.
After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays whether 75%, 80%, or 100% of the costs of covered benefits depending on your policy plan after out of pocket has been met. The out-ofpocket limit doesn’t include your monthly premiums.
The lifetime maximum insurance benefit is the maximum dollar amount that your insurance company will pay for your infertility treatment.
If your lifetime maximum is 15K and you exceeded the benefit amount as stated, you will now be responsible for any payment your insurance company pays the health care provider above the 15K.
Annually, the insurance company makes an audit on their paid claims to health care providers. During this time, they will recoup any monetary exceeded above patient’s lifetime maximum benefits. It is your responsibility to pay this recouped amount to the healthcare provider.