Managed care
In terms of using such a plan, unlike an HMO plan, which has a copayment cost share feature (a nominal payment generally paid at the time of service), a PPO generally does not have a copayment but offers a deductible and a coinsurance feature. The deductible must be paid in full before any benefits are provided. After the deductible is met, the coinsurance benefits apply. If the PPO plan is an 80% coinsurance plan with a $1,000 deductible, the patient pays 100% of the allowed provider fee up to $1,000. The insurer will pay 80% of the other fees, and the patient will pay the remaining 20%. Charges above the allowed amount are not payable by the patient or insurer but written off as a discount by the physician.
Affordable Care Act tax provisions
Individuals who were not insured during the tax year are required to make a payment when filing their tax return, unless they qualify for a tax exemption. An exemption certificate number is required in some cases for obtaining an exemption on a tax return. In 2014 the payment amount was 1% of income or $95 per adult ($47.50 per child) limited to a family maximum of $285 (national average premium for a bronze plan), whichever is greater. In 2015 the penalty increased to $285 per adult or 2% of income above the limit.