Copays? Coinsurance? How does this all work?

A simplified guide to how health insurance payments work for you, the insured.

Definitions

• Co-pay: A specific dollar amount you pay for certain services (example Dr visit, Drugs). When the service has a co-pay the deductible does NOT apply.
• Deductible: The amount of medical expense that you pay at 100% of cost.
• Co-Insurance: The % of medical expense that you SHARE with the Insurance Company AFTER you have met your deductible. You pay this until you meet...
• Max out-of-pocket: The most that you will pay for covered medical expense in a calendar year (Equals your deductible + co-insurance). After this is met, insurance pays 100% of covered costs.

Deductible and Co-Insurance Workflow (Slide 3)

Worst Case Scenario Example (Slide 4)

HMO is "Health Maintenance Organization"

• You MUST choose a Primary Care Dr. in the HMO network
• You MUST receive a written referral from their Primary Care Dr to a Specialist in the HMO network
• The HMO network will have fewer Dr.’s
• There are no benefits OUT OF NETWORK
• Provides cost-effective access to care, especially for those with few needs

PPO is "Preferred Provider Organization"

• You do not need to choose a Primary Care Dr.
• You do not need a referral to a specialist
• The PPO network will have the most Dr.’s
• You may receive some (limited) benefits out of network
• Offers the most freedom of choice at a higher cost per month

EPO is "Exclusive Provider Organization"

• Much like a PPO, but with one crucial difference*
• You do not need to choose a Primary Care Dr.
• You do not need a referral to a specialist
• The PPO network will have the most Dr.’s
• You may receive some (limited) benefits out of network
• Offers the most freedom of choice at a higher cost per month
• *No out of network coverage