Co-Pay and Deductible Information
A Copayment (Copay) is the fixed dollar amount that each insured is responsible to pay when receiving certain medical services. For example; The Copay for Primary Care Physicians is $30, for Specialists it is $45. Emergency Room services are subject to a $100 Copay per visit. The Emergency Room Copay will be waived if immediate admission to the hospital is required. In some cases like Emergency Room services, a Deductible may need to be satisfied in addition to a Copay. See Deductible for an explanation.
Retail drugs are also subject to a Copay. Generic Drugs have a minimum of $10 Copay, Brand Formulary, minimum of $20 Copay, and Brand Non-Formulary, minimum of $40 Copay.
The optional Vision plan has a $45 Copay per visit.
Additional information concerning Copays may be found in the Summary Plan Description (SPD) in the Schedule of Medical Benefits section.
The Deductible is the dollar amount of Eligible Medical Expenses each insured is responsible for paying during each calendar year before the Plan begins to pay benefits. The amount of deductible the insured is responsible for depends on the type of plan that has been selected, i.e…. Trust1500 or Trust2500. The Deductible is the lesser of billed charges or the Allowed Charge under the plan. Deductibles are accumulated on a Calendar Year basis and only covered eligible expenses can be used to satisfy the Plan Deductible. Not all expenses are covered and therefore do not count towards the Deductible. Copays are not counted toward the Deductible.
There are two types of Deductibles, Individual and Family. The Individual Deductible is the maximum amount of eligible expenses an individual insured must pay before the plan begins to pay. The Individual Deductible varies based on the plan option selected by the insured (i.e…. Trust1500, Trust2500…)
The Family Deductible is the maximum amount of eligible expenses that a family of two or more insureds must pay before the plan begins to pay. The Family Deductible varies based on the plan option selected.
For information on expenses not subject to the Deductibles and for the HDHP (Trust3000) refer to the SPD.
Once an insured has met the annual Deductible, the Plan generally pays a percentage of the eligible expenses. The insured, NOT the Plan is responsible for the balance of the eligible expenses. The part the insured pays is the patients share of the coinsurance. Payment by the Plan will be greater when In-Network providers are utilized. If the insured chooses to see a Out-of-Network provider for Medical Services the insured will pay a higher percentage of the charges. Refer to the SPD, Schedule of Medical Benefits for additional details concerning the Coinsurance.
Maximum Out-of-Pocket Expenses
Each Calendar Year after an insured (or family) pays the maximum Out-of-Pocket expenses for Coinsurance; the Plan will pay 100% of covered eligible charges. The Plan rarely pays benefits equal to the medical expenses incurred, as a result Out-of-Pocket expenses that the insured must always pay include; Plan Deductibles, Copays, expenses not covered by the Plan, charges in excess of the Allowed Charge, services in excess of Plan benefits, and cost incurred for failing to comply with the Utilization Management Requirements. Out-of-Pocket Maximums “cross accumulate” between in-network and out-of-network expenses. When Out-of-Network providers are utilized, the Maximum Out-of-Pocket will be greater. Refer to the SPD, Schedule of Medical Benefits for additional details concerning Out-of-Pocket Expenses.
Co-Pay and Deductible Examples
An insured goes to see a Primary Care Doctor. The charge for the office visit is $150. The insured will pay a $30 Copay at the time of the service. The bill for service of $150 is submitted to the Plan for contractual provider discounts and Plan determination of payment. The claim is discounted to a remaining balance of $100. If the Yearly Deductible has not been met, then the balance will be deducted from the insured’s Deductible amount.
i.e…. Using the Trust1500, with no deductibles satisfied for the year,
|Balance after Discount||$100.00|
|Less Balance after Discount||$100.00 (Paid by Insured)|
An insured goes to see a Specialist, the charge for the visit is $750. The insured will pay a $45 Copay at the time of the service. The balance of $705 is submitted to the Plan for contractual provider discounts and Plan determination of payment. The claim is discounted to a remaining balance of $675. If the Yearly Deductible has not been met, then this balance will be deducted from the insured’s Deductible amount.
i.e…. Using the Trust1500,
|Less Balance after Discount||$675.00|
|Balance to Deductible||$675.00|
|Less Specialist Visit||$675.00 (Paid By Insured)|
An insured goes to the hospital for a non-emergent, non-admitting visit. The charge for the visit is $2,500. Insured will pay a $100 Copay at the time of the service. The balance, $2400 is submitted to the Plan for contractual provider discount and Plan determination of payment. The claim is discounted to a remaining balance of $2,000. If the Yearly Deductible has not been met, then this balance will be deducted from the insured’s Deductible amount.
i.e…. Using the Trust1500,
|Less Balance after Discount||$2,000.00|
|Balance to Deductible||$2,000.00|
|Less Hospital Visit||$705.00 (Paid By Insured)|
|Balance submitted to the plan for Payment||$1,295.00|
Maximum Out-of-Pocket Example
Assuming an individual insured using the Trust1500 Plan, $1,500 deductible, has reached the maximum deductible level, $1,500, the maximum Out-of-Pocket expense using an In-network PPO would be an additional $2000. This is a total for the year of insured expense of $3500.
i.e…. Using the Trust 1500
|Covered Eligible Claims||$12,500.00|
|Balance of Eligible Claims||$11,000.00|
|20% Coinsurance by insured||$2,000.00 Max Out-of-Pocket|
|Plan Paid Insurance||$9,000.00|
|Total Out-of-Pocket Expense by Insured||$3,500.00 ($1,500 + $2,000 = $3,500)|