There seems to be some confusion about office visit copays and health insurance deductibles work together.

The most common belief is that one must satisfy their deductible before their health insurance kicks in.

This is a misunderstanding.

Lets look at an example:

Plan Deductible: $5000

Office Copay: $30

Prescription Copay: $15

Scenario: Doctors visit for chest congestion.  Doctor prescribes prescription.

In this scenario, you would pay $30 for the office visit and $15 for your prescription coverage.  Your health insurance plan would cover the additional cost of the office visit and prescription.  Yes, even with a $5000 deductible.

The simplest way to understand the plan deductible is to look at it this way:

Your deductible is triggered for Inpatient hospitalization services, Outpatient services, and Emergency room services.  Depending on your plan it may also come in to play for x-rays and labs.  Always be sure to read your plan documents to fully understand your coverage.

This means if you go to the doctor because you have a bad cold or the flu, you only pay your office visit copay.  You do not.  I repeat, do not have to satisfy your deductible before you use these benefits.

We wrote about this last year:

Do I Have To Satisfy My Deductible To Use Office Visit Copays?

Originally posted 2010-04-01 06:03:26. Republished by Blog Post Promoter

An office visit copay is the flat dollar amount that you would pay for a routine visit to either a primary care physician or a specialist, with coverage kicking in at 100% after the copay.  Most traditional, employer sponsored plans offer an office visit copay.  However, individual and family plans may or may not include office visits copays as part of the coverage.

SOME of the plans listed in your instant quote will not offer copays for routine office visits.  If you see “$0″ or “N/A” in the Copay column on your instant quote, then those plans will not have an office visit copay.  On plans with no office visit copay, routine office visits will typically apply to your deductible, and you will be responsible to pay the network-discounted rate for office visits until your deductible is met.  On some of the catastophic plan designs with no copays, routine office visits may not even be covered at all!

Carriers that do not offer office visit copays on their basic plan design will usually give you the option to add office visit copays for an additional premium.  Please remember that when you pay a copay on a PPO plan, your deductible IS NOT reduced by the amount of that copay.  Copay expenses, whether for office visits or prescriptions, are unlimited and never included in your PPO plan’s maximum out-of-pocket limit.

Originally posted 2009-10-09 04:54:29. Republished by Blog Post Promoter

Frequently Asked Questions

If you have a health insurance plan that states office visit copay: 20% after deductible, what is the cost of your office visit?

Great question. If your plan does not include office visits prior to the deductible, you are responsible for the full cost of the office visit. That is, until you satisfy the deductible.

Once you satisfy your deductible you would be responsible for 20% of the cost of the office visit.

Example:

• You have satisfied your deductible
• Doctors Office charges you $100 for an office visit
• The insurance company would pay $80 dollars towards the office visit
• You would be responsible for the remaining $20 dollars.

Frequently Asked Questions

If you have a $0 copay for office visits after your deductible, how much does your office visit cost? That depends.

At first glance, without knowing what your copay before the deductible, all indications would be that you would pay nothing for your office visit. Of course assuming you have satisfied your deductible.

If you haven’t hit your deductible and you aren’t sure what your copay is before the deductible, a quick way to figure that out would be to look at your health insurance card.

Here is an example:

A quick review of the left side of the card shows your office visit copay is $25.  $35 for a specialist.  It also lists your X-Ray, Lab, and prescription benefits.  Your card may be different.

If you have questions please comment or feel free to ask us anonymously at http://www.formspring.me/michiganhealth

Make it a great day!

Billy