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How do Copays, Coinsurance and Deductibles Work?


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Copays, Coinsurance and Deductibles work in different ways. Let’s explore what they are and how they work.


Copays are flat fees for a certain type of service, visit or when you fill a prescription. Copays are charged each time you have the service or fill the prescription and are usually collected the day of the service.


Example:

Mary visits her Primary Care Physician; her plan has $5 copay for Primary Care Visits. When she checks in for her appointment, the front desk asks for her $5 copayment before she sees the doctor.


Coinsurance is a percentage amount of the total services provided, based upon the final approved bill. Coinsurance is not usually collected at the time of service. After the charges have processed and been approved by the insurance carrier, your provider would send the due amount to you. You are responsible for this amount up to your maximum out-of-pocket if you plan has one.


Example:

Marty has a service that has 20% coinsurance. The approved amount was $3,000. He will have coinsurance of $600 due.


Deductibles are amounts required to pay before copays or coinsurance are charged.

There are different types of deductibles depending on the coverage and plan types you are enrolled in.


Medicare Part A Deductible

In 2023 Medicare Part A has a $1,600 deductible for each benefit period. The benefit period starts the day you are admitted as inpatient to the hospital and ends when you have been out of the hospital 60 days without any covered inpatient hospital stays or skilled nursing stays.


Example:

Mark is admitted to the hospital in January and stays 5 days. He is readmitted in April and stays for 5 days. More than 60 days pass between Matthew being released and readmitted.


Mark's Costs

​1st Stay

Medicare Part A Deductible

$1,600

​Days 1- 5

$0

​2nd Stay

Medicare Part A Deductible

$1,600

​Days 1- 5

$0

Total Costs

$3,200


Medicare Part B Deductible

In 2023 the Medicare Part B deductible is $226. Once you have paid this amount for the year, your Part coverage kicks in.


Medicare Part D Deductible

Part D coverage may have a deductible for certain tiers of drugs or no deductible at all depending on your plan. If there is a deductible, you pay that amount first and then you will have a copay or coinsurance when filling the prescription.


Perfiniti knows these terms can be confusing. Our Licensed Agents are available to answer your questions at 888.885.8361

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