California health insurance    Understand health insurance in California    Copays for health plans

How office copays work with some California health insurance plans

Office Copays used to be the calling card of health plan names.  You had the $20 copay or the $40 copay plan.  That was back when we had low or no deductible plans and people would fixate on the smaller benefits such as an office copay.  Things have really changed in the ten years that passed.  If only office copays were our biggest concern these days.  Let's look at what the office visit copay is and how it works.

The office copay of California health insurance plans is a fixed amount that you will pay for an office consultation with a physician.  Most plans do not distinguish between a general practioner and a specialist.  The amount is usually the same either way.  The copay is paid up front at the doctor's office upon receipt of services.  Your health insurance card usually shows the the copay amount.  Keep in mind that the copay amount only covers the consultation itself.  If you have labs or small procedures completed during the office visit, these require additional payments above the beyond the copay amount which is usually handled with a deductible or coinsurance amount. 

Many of the popular Individual family PPO health insurance plans on the market offer a certain number of copays up front (2-4 depending on the plan) after which, additional office visits are subject to the main deductible.  Preventative benefits are now covered at 100% in-network for eligible expenses on plans effective after 3/23/2010.  Grandfathered plans are not subject to this main mandates including the 100% preventative benefit.  The common office visits under preventative are for routine physicals, annual pap and mammograms or ObGyn visits, well child visits, and well woman visits. 

HSA plans handle office visits differently.  With the HSA plans, office visits are subject to the main plan deductible.  This and medication are two key differences between HSA health plans in California and the standard PPO plans.  On HSA plans, you would pay the negotiated PPO rate in full which can fluctuate depending on what the doctor charges (and type of doctor).  Keep in mind that the negotiated PPO rate for a doctor probably run from $80 on up.

The copay benefit only applies if you use in-network PPO providers on PPO plans.  If you use a non-network provider in a non-emergency situation, you can expect to pay quite a bit more.






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