First, an
explanation
of office
copays and
how they
work
Office
Copay
This is
a main
component
of the
benefit
summaries
you will
see
when you
receive
an
instant
health
quote.
With
most
plans on
the
market,
you will
pay a
fixed copay
for the
office
consultation.
For
example,
you may
see
"$10"
under
the
office
visit
column.
This
usually means
that you
will pay
$10 when
you see
a
doctor.
What is
covered
by the
office
copay
One
important
item...the copay
only
covers
the
consultation
itself.
If the
doctor
requests
labs or
performs
other
procedures
(such as
a
dermatologist
performing
a skin
biopsy),
that
procedure
is
usually not
covered
under
the
office copay.
It will
either
have a
separate
copay
(typical
with
HMO's);
be
subject
to a
plan
deductible;
or
subject
to
co-insurance
percentage
sharing.
Labs are
also in
addition
to the copay
amount
you pay.
Usually
there is
a flat
copay
amount
for
general
physicians
and
specialists
on the
California
health
insurance
market.
An
exception
to this
"copay
only for
the
consultation"
rule can
be found
with the
Tonik
health
plans
from BC
Life and
Health
(Blue
Cross).
The
tonik
plans
were
designed
to make
the
office
copay
more
inclusive.
You can
run an
Individual
Family
health
quote
and
check
the
Tonik
benefits
to
compare.
The
office
visits
usually
do not
make a
distinction
between
the type
of
doctor...specialist
or
general
practice
physician.
How are
routine
physicals
handled
with
office
copays
Routine
physicals
are
usually
handled
separately
from
standard
office
visits.
Depending
on the
health
plan,
they may
have a
similar
copay
but they
may also
be
subject
to the
main
deductible.
Some
carriers
such as
Blue
Cross of
California
may
require
certain
providers
for
routine
physicals.
It's
important
to look
at the
benefits
of your
particular
health
plan or
the
insurance
plan you
are
looking
at to
see how
it
treats
routine
physicals.
You may
have an
office
copay
for the
routine
physical
but
resulting
labs
such as
blood
panels
may be
handled
separately.
Some
health
plans
offer no
or
limited
office
copays
There are
plans on the
market as
part of an
ongoing
trend to
reduce
health care
costs
that do not
offer office
copays or
have a fixed
number of
them per
year.
The HSA
qualified or
Health
Savings
Accounts
plans
typically
apply office
visits to
the main
deductible.
This usually
means you
will pay the
full
discounted
PPO rate
(if
in-network
for covered
benefits)
for doctor
visits until
you meet the
deductible.
There are
other
hospital
plans (for
catastrophic
coverage)
that usually
do not cover
office
visits.
Other plans
limit the
number of
office
visits a
person can
have in a
calendar
year.
Once you use
your number
of office
visits, you
will usually
pay the full
negotiated
rate or a
percentage
of the
negotiated
rate for
covered
benefits,
in-network.
Office visit
copays and
network
considerations
With a PPO
plan, your
choice of
providers
can affect
your
out-of-pocket
expenses.
The copay
shown in
your health
quote
usually
refers to
using
in-network
doctors.
If you use
out-of-network
providers,
you will
usually pay
more out of
pocket than
just the
in-network
copay.
With HMO's,
you want to
work through
your Primary
Care
Physician
and HMO
medical
group.
Usually with
HMO plans,
you will no
benefits
outside the
scope of
your PCP or
medical
group.
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