Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) Your cost sharing does not depend on whether a provider is in a network. Your Cost if You Your Cost if You Common Services You May Need Use an In-Network Use an Limitations & Exceptions Medical Event Provider Provider Primary care to treat an injury or If you visit a 20% coinsurance 20% coinsurance --------none-------- illness health care Specialist visit 20% coinsurance 20% coinsurance --------none-------- provider’s office Manipulative Therapy or clinic Coverage is limited to 60 visits per benefit period including Acupuncture, Physical, Occupational and Speech Manipulative Therapy Manipulative Therapy Therapy includes manipulations only 20% coinsurance 20% coinsurance regardless of provider specialty. Costs Other practitioner office visit Acupuncture Acupuncture may vary by site of service. 20% coinsurance 20% coinsurance Acupuncture Coverage is limited to 60 visits per benefit period including Chiropractic, Physical, Occupational and Speech Therapy. Preventive No cost share No cost share Hearing exam (routine): Not covered care/screening/immunization If you have a test Lab Office Lab Office Lab Office – – – 20% coinsurance 20% coinsurance Pre-certification may be required. Diagnostic test (x-ray, blood work) X-Ray Office X-Ray Office X-Ray Office – – – 20% coinsurance 20% coinsurance Pre-certification may be required.
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) Your cost sharing does not depend on whether a provider is in a network. Common Medical Event Services You May Need Your Cost if You Use an In-Network Provider Your Cost if You Use an Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care to treat an injury or illness 20% coinsurance 20% coinsurance --------none-------- Specialist visit 20% coinsurance 20% coinsurance --------none-------- Other practitioner office visit Manipulative Therapy 20% coinsurance Acupuncture 20% coinsurance Manipulative Therapy 20% coinsurance Acupuncture 20% coinsurance Manipulative Therapy Coverage is limited to 60 visits per benefit period including Acupuncture, Physical, Occupational and Speech Therapy includes manipulations only regardless of provider specialty. Costs may vary by site of service. Acupuncture Coverage is limited to 60 visits per benefit period including Chiropractic, Physical, Occupational and Speech Therapy. Preventive care/screening/immunization No cost share No cost share Hearing exam (routine): Not covered If you have a test Diagnostic test (x-ray, blood work) Lab – Office 20% coinsurance X-Ray – Office 20% coinsurance Lab – Office 20% coinsurance X-Ray – Office 20% coinsurance Lab – Office Pre-certification may be required. X-Ray – Office Pre-certification may be required.