Understanding Co-Pays, Deductibles and Coinsurance
A co-pay is usually a set dollar amount that you pay out-of-pocket every time you receive certain medical services.
Listed below are the other co-pay charges for services from Aetna network providers:
Mail-Order Prescriptions $10 (Generic)
$20 (Brand Name)
|Urgent Care/Walk-in Clinic
|Some Doctor Office Visits*
|Routine OB/GYN Exam
for Children to Age 6)
* The co-pay usually applies to primary care physician visits but not to visits with specialists (such as allergists and surgeons), therapists, and chiropractors.
A deductible is an annual dollar amount you have to pay for medical services each calendar year - before insurance pays any benefits. For the MPS Aetna plan, the deductible is $100 per person per year.
Example: If you visit a chiropractor for your first medical service of the year, at $80 per visit, you pay the entire $80 for the first visit. For the second visit, you pay $20 before the Aetna payment and your coinsurance payment are calculated on the remaining $60.
For a family, the $100 deductible applies to each individual, but when 3 family members reach their $100 deductible amount in a year, there is no deductible for other family members.
Coinsurance is your payment share for a medical service, with your insurance paying the rest of the cost. The coinsurance is a percentage of the bill. For medical services from an Aetna network doctor, your share is 10%. (Out-of-network, your share is 20%).
Coinsurance payments are assessed after your $100 deductible is met each year.
There is a cap on the total amount of coinsurance you pay per person each year -- a maximum of $200 (in-network) and $500 (out-of-network).
Example: If you are hospitalized (in-network) in early January and your first medical bill for the year is $25,000, you pay $100 to meet your deductible. Your coinsurance payment is 10% of the remaining $24,900; however it is capped at $200 for the year. So you pay a total of $300 -- $100 deductible and $200 coinsurance. Aetna pays the rest.
For a family, the annual coinsurance cap applies to each individual, but when 3 family members each reach their coinsurance cap in a year, there are no coinsurance payments for other family members.
Out-of-Network More Costly
If you receive services out-of-network, your coinsurance payment:
There is a risk that the out-of-network provider will charge in excess of the usual, customary, reasonable fee. You are responsible for the excess amount.
Example: Suppose you incur a $5,000 bill for a procedure you received from an out-of-network physician, but Aetna has established a usual, customary and reasonable (UCR) fee of $4,000 for the surgery. Based on 20% of $4,000 the coinsurance amount would be $800. Because of the $500 coinsurance cap, you would pay $500, and Aetna would pay $3,500 of the $4,000 UCR amount.
However, you would be responsible for paying an additional $1000, the amount in excess of the usual, customary, and reasonable fee.