What is a copay?
This is a fixed amount that you must pay for a covered service, as defined by your health plan. Copays usually vary for different plans and types of services. Typically, you must pay this amount at the time of service. Again, copay amounts are fixed—which means you will always pay the same amount, regardless of visit length. In most cases, copayments go toward your deductible.
What is a coinsurance?
This type of out-of-pocket payment is calculated as a percent of the total allowed amount for a particular service. In other words, it’s your share of the total cost. For example, let’s say:
- Your insurance plan’s allowed amount for an office visit is $112.46.
- You’ve already met your deductible.
- You’re responsible for a 20% coinsurance.
In this situation, you’d pay $22.49 at the point of service. The insurance company would then pay the rest of the allowed amount for that visit. Keep in mind that the coinsurance amount may vary from visit to visit depending on what services you receive.
A Couple of NOtes?
- Most insurance companies offer several different plans or subsidiaries. Thus, two patients with Blue Cross Blue Shield, for instance, may have completely different benefits, and therefore, completely different financial responsibilities. Some plans have no copays or deductibles; others may have a $10,000 deductible. Furthermore, some providers may not accept all plans from a particular insurance. This is why it is crucial that you investigate the details of your specific plan.
- If your insurance offers an online patient portal, sign up for it! These resources typically enable you to:
- Check your benefits,
- Track your deductible,
- See which providers in your area accept your particular plan,
- Track your claims, and compare claims to your receipts from the doctor’s office (if they don’t match up, you can then follow up on any discrepancies).
What is the coinsurance for Medicare Part B?
Medicare Part B patients are responsible for a 20% coinsurance, which typically amounts to $11-25 per visit. If you have original Medicare as your primary insurance, but you also have a secondary insurance, the secondary payer becomes responsible for the 20%. In some cases, the secondary insurance also charges a copay, coinsurance, or deductible. We recommend contacting your secondary insurance carrier to find out.
How much will I owe for each visit?
What if I can’t afford to pay these amounts as frequently as I need care?
A Few Handy Definitions
Date of Service
Tips for Choosing an Insurance Plan
What is my premium?
What is my deductible, and what does it apply to?
What is my copay?
What is my coinsurance?
Are there any restrictions on the types of providers I can see?
Do I have to get a referral to see a specialist?
How many visits of "X" am I allowed each year?
For Medicare secondary payers: Will this plan cover the entire 20% not covered by Medicare
The Bottom Line