A deductible is the amount a patient pays for health care services before health insurance begins to pay.
Let's say the insurance plan's deductible is $1,500. That means for most services, the patient will pay 100% of medical and pharmacy bills until the amount paid reaches $1,500. After that, the patient responsibility will depend on the plan's coinsurance. If the plan covers 80% once the deductible is met, the patient is responsible for the remaining 20% of charges.
Beach Cities Orthopedics collects up front if the patient's deductible has not been met. We collect $150 for the initial visit and $70 for follow up visits.
If the deductible is met, BCO will not collect any amount up front. The claim bill be submitted to insurance, and once the patient's insurance processes the claim, the patient will be billed for the coinsurance.
Coinsurance is the patient's responsibility for health care services once the deductible has been met. It is a percentage of the amount billed for services. Patients start paying coinsurance after they have paid their plan's deductible.
Here's how it works: Lisa has knee pain, so she sees a doctor regularly. She just paid her $1,500 deductible. Now her insurance covers 80% of the cost of her knee injections because her deductible is met. Lisa pays the remaining 20%; that's her coinsurance.
A copay is a fixed amount (set by the insurance plan) that patients pay for a health care service. It is collected at the time of service. The amount can vary by the type of service. The insurance pays the remaining charges.
For example, a doctor's office visit might have a copay of $20. The copay for specialist visit often has a higher cost, such as $45. For some services, there may be both a copay and a coinsurance.
The out-of-pocket limit is the maximum amount of money a patient will spend on health care services each year. Generally, but not always, this includes both copays and coinsurance. It may or may not include the patient's deductible.
Once the out-of-pocket maximum is met, the patient's coinsurance, and sometimes copay, will be waived. At this time, the insurance company will cover medical expenses at 100%. Some plans do not include the copay in the out-of-pocket maximum, so the copay will always apply to services.