What are Copays, Deductibles, and Co-insurance, you may ask? A lot of these terms can be overwhelming to most of us. Luckily here at Coastal Orthopedics, our knowledgeable staff can guide you through these and help you to become familiar with their meaning and function in your health care.
Something important to keep in mind regarding copayments, coinsurances and deductibles. All these costs do apply towards your Out of Pocket Maximum. Once your Out of Pocket Maximum is met, your plan usually covers 100%.
Out of Pocket Maximum is the most amount of money that you as the member, will have to pay towards the cost of your covered healthcare.
Copays is a payment a patient makes in relation to the office visit attended; this is a fixed amount. Depending on the level of plan you have for your health insurance, your copay amount can vary. Some things to keep in mind regarding Copayments.
- Copays are usually a flat dollar amount pre-determined by the members' plan.
- Copays are a portion of the cost of service or services provided.
- Copays can either take effect before or after a deductible has been met.
- Copays are not always applied to the office visit only. If no office visit charge is present, for example, some plans may apply the copay to an x-ray.
A deductible is a specified amount of money that the insured must pay before a carrier covers a claim. Deductibles can vary depending on the level of plan you have selected. Some plans have separate deductibles for specific services like prescription drugs, surgery, or fracture care.
It is always good to keep track of your remaining deductible. This allows you to better prepare and estimate any out of pocket cost should a need for a major procedure arise.
- Another important note to remember: most plans treat fractures as surgeries and therefore they can apply towards your deductible.
- Other services that could apply towards your deductible are: lab tests, MRI’s, CAT scans, anesthesia, etc.
- Co-insurance is a percentage of the allowed cost for a procedure that you as a patient pays. This only continues until you have met your plan's out of pocket for the year.
- Often, specific plans will apply a co-insurance as well as a copay; the members' plan determines this.
A global period is a period of time starting at the initial office visit your fracture is diagnosed, or the day your surgery takes place. (note this includes fractures based off AMA surgical coding guidelines) The global period ends within a set period of time after the procedure (10 or 90 days). The follow-up period after a surgery or global period covers follow up treatment pertaining to the surgery as it is bundled into the initial surgical cost.
- The global period is the period of time or coverage after a surgical procedure. A surgical procedure can range from an injection, fracture, or operative procedure.
- Follow up care pertaining to the initial surgery is covered during a global period; it is important to note exceptions apply such as x-rays, injections, and so forth.
- A global period is also called a post-operative period.
- Fractures can count as surgery and therefore have a global period of 10 or 90 days.
A common misconception is that the only thing due during an office visit is the copay, the real answer is it depends. A co-insurance may apply during your visit if there are any procedures done in office; this is separate from what's included in your copay based on your plan. Co-insurance can apply to procedures done in office such as x-rays, injections, fracture care, and so forth. Another way to look at it, copays are typically due before a visit whereas co-insurance is due after the visit once a procedure has been performed, if applicable.
Another common misconception involves fracture charges; Per the coding guidelines insurance carries classify most fractures as a surgical procedure. This means that a deductible may be applied. A global period also applies to most* fractures.
Not all plans utilize copayments as a method for the member to share in the covered expenses and/or costs. Some plans do not have copayments; instead, they have coinsurances or deductibles that are used towards the Out of Pocket Maximum.
Here at Coastal Orthopedics, we understand that deductibles can be high. We try to help our patients as best as we can and offer options when it comes to high deductibles.
One way is through Care Credit. Care Credit is a line of credit that can be used toward medical expenses. You can apply in office online or via your smartphone at carecredit.com. Care Credit offers several financing options so that you may select what is best for your situation. You will receive your response typically, within minutes.
Another option is in-house payment plans. We offer financing options to patients with balances over $100. This could be a 3-month payment plan with a requirement of having a credit/debit card saved on file. Payments will be deducted automatically on dates set by our system and approved by you. You will be provided the payment dates so that you can ensure that it processes.
It is important to know precisely what your plan covers and how; as well as knowing what payment options we have available to you.
Now that you have become familiar with the terms that make up your benefit plan, you will find that understanding your plan as well as anticipating your out of pocket expenses will be so much easier.
Our goal here at Coastal Orthopedics is that our patients get the care they need when they need it — making options accessible to our patients, keeping their health in our focus.
If you feel you require any Orthopedic care or wish to come in for a chronic problem feel free to give us a call or apply for an appointment today.