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Understanding healthcare cost and especially your insurance plan can be confusing. That's why we thought it would be helpful to provide you with the meaning of commonly used terms such as copays, deductibles, and coinsurance. Knowing these important terms may help you understand when and how much you need to pay for your visit at Peachtree Primary Care or any other provider. Let's take a look at these definitions in depth, how they work together and how are they different.


What is it?

copay (or copayment) is a flat fee that you pay on the spot each time you go to your doctor or fill a prescription. For example, if you hurt your back and go see your doctor, the amount you pay for that visit or medicine is your copay. Most times, your copay amount is printed right on your medical insurance ID card. Copays cover your portion of the cost of a doctor's visit.

Do I always have to pay copay?

Not all plans use copays to share in the cost of covered expenses. Or, some insurance plans may use both copays and a deductible/coinsurance, depending on the type of covered service. Also, some services may be covered at no out-of-pocket cost to you. Examples of these could include annual physicals/checkups and certain other preventive care services. Please consult your medical insurance carrier for additional information.


What is a deductible?

deductible is the amount you pay each year for most eligible medical services before your health plan begins to share in the cost of covered services. For example, if you have a $2,000 yearly deductible, you'll need to pay the first $2,000 of your total eligible medical costs before your plan helps to pay. It’s always a great idea to call the number on the back of your insurance card to gain further clarity.

Deductibles for family coverage and individual coverage are different. Even if your plan includes out-of-network benefits, your deductible amount will typically be much lower if you use in-network doctors and hospitals.

What is the difference between a deductible and a copay?

Depending on your health plan, you may have a deductible and copays. A deductible is the amount you pay for most eligible medical services before your health plan begins to share in the cost of covered services. If your plan includes copays, you pay the copay flat fee at the time of service. Depending on how your plan works, what you pay in copays may count toward meeting your deductible. 


What is coinsurance?

Coinsurance is a portion of the medical cost you pay after your deductible has been met. Coinsurance is a way of saying that you and your insurance carrier each pay a share of eligible costs that add up to 100 percent. Coinsurance is often confused with Copay and it’s important to note that these are two distinct benefits within a plan.

What is an out-of-pocket maximum?

Out-of-pocket maximum is the most you could pay for covered medical expenses in a year. This amount includes money you spend on deductibles, copays, and coinsurance. Once you reach your annual out-of-pocket maximum, your health plan will pay your covered medical and prescription costs for the rest of the year.

Important reminder 

As a primary care provider for you and your family, we do our best to help our patients understand how their medical insurance may work. Your insurance is a contract between you (patient) and your medical insurance company. Although we will do our best to help you understand what your benefits may be, it is always a great practice to call the number on the back of your insurance card to check your particular plan.

It is important to note that there are hundreds of medical insurance plans out there, and each one has rules that may be different from one another. Many times a same insurance provided by two employers to two different patients may have significantly different coverages.