A set dollar amount you pay when receiving specific services. Copays do not apply to your deductible, coinsurance, or out-of-pocket maximum and not all services require a copay.
Example of how a copay works
Sally takes her son, Charlie, to the pediatrician for a bad cough. Sally pays the office visit copay ($10 or $30) at the doctor's office.
The amount you pay each calendar year before your health plan starts to pay for covered services with coinsurance. You will be responsible for paying the first $500 ($1,000 out-of-network) of certain covered medical costs before your health plan pays the 70% (50% out-of-network) of the covered services. The annual deductible must be met for each family member enrolled in Washington Health. The deductible does not apply towards the annual out-of-pocket maximum.
Example of how a deductible works
John falls off his roof and is taken to the hospital by ambulance. The ambulance service is subject to his annual deductible. John has not paid anything toward his deductible, so he is responsible for the first $500 of the $600 cost. He also is responsible for paying 30% coinsurance of the remaining bill.
|John pays 30% of remaining bill||$30|
|Health plan pays 70% of remaining bill||$70|
|John's total cost||$530|
Because John met his $500 deductible, he will only pay copays and the 30% coinsurance for the rest of the year until he reaches his out-of-pocket maximum.
The percentage you pay when your health plan pays less than 100% for covered services. Your health plan will not pay toward services with a coinsurance until you have paid your annual deductible. You will be responsible for paying 30% (50% out-of-network) of the cost of services that have a coinsurance. Your health plan will pay the remaining amount.
Example of how a coinsurance works
Sally is hospitalized for an injury. The hospital stay costs $1,000. The hospital stay is subject to her annual deductible. Sally has already paid her annual deductible, so she pays 30% coinsurance for the hospital stay and her health plan pays the remaining 70%.
|Sally pays 30%||$300|
|Health plan pays 70%||$700|
Your coinsurance costs apply toward your out-of-pocket maximum of $3,000 ($5,000 out-of-network) per person, per calendar year. When you or another covered family member reaches the out-of-pocket maximum, you are not responsible for any further coinsurance costs for covered services received by that person during that year. Your health plan will pay 100% of the charges for all coinsurance costs. However, you will still be required to pay applicable copays.
Example of how out-of-pocket maximum works
When John fell off the roof, he seriously damaged his knee. He will need three surgeries to repair the damage. Each surgery will cost $5,000 and his coinsurance is 30%. The surgeries are subject to his annual deductible, which he has already met with the ambulance service.
|John pays 30%||$1,500|
|Health plan pays||$3,500|
For the second surgery, John will not have to pay the full 30% coinsurance, because he has already paid $30 for the ambulance service and the $1,500 for the first surgery, that go toward his annual out-of-pocket maximum of $3,000.
|John pays the remainder of his $3,000 out-of-pocket maximum||$1,470|
|Health plan pays||$3,530|
As long as the third surgery occurs in the same calendar year, John will not have to pay any deducible or coinsurance because he has already paid his out-of-pocket maximum with the ambulance service and the first two surgeries.
|Health plan pays||$5,000|
John will still be responsible for paying his copays for follow-up office visits, prescription drugs, and for non-covered services.
Explanation of Benefits (EOB)
Each time you receive medical services, Community Health Plan will send you a detailed statement explaining which procedures and services were given, how much they cost, how much your plan pays, and how much you pay.