A PPO has contracts with a network of preferred providers. If you receive care from a doctor in the network, then you are only responsible for your annual deductible, your copayment for the visit and, possibly, coinsurance. If you receive health services from a provider that is not in the network (known as going “out-of-network”), then you will pay a higher amount. Check out the Glossary of Terms for definitions of deductibles, copays, coinsurance and out-of-pocket maximums.
- Your deductible is satisfied by all services, including most doctor visits.
- You pay a copay when you visit the doctor, ER or urgent care center—up to your annual out-of-pocket maximum—and when you get prescriptions.
- The copay for office visits covers the basic evaluation. If additional services (lab tests, x-rays, EKGs, etc.) are provided during the visit, the coinsurance provision applies after any deductible has been satisfied.
- For hospital-based services, you pay 100% of the costs each year up to the deductible. After your deductible is satisfied, you begin sharing expenses with the plan – that’s coinsurance. You pay a small percentage of the expenses after your deductible is met, then the plan begins paying the larger portion of your covered expenses.
- After you reach the out-of-pocket maximum, the plan pays 100% of covered expenses for the rest of the calendar year. If you have family coverage (any dependents), once one person satisfies the individual deductible, he or she can start receiving benefits that are payable after the deductible.
- Copays don’t apply to the deductible, but are counted toward your out-of-pocket maximum.
Paying for Your Expenses
- Your health ministry may make contributions to a Health Reimbursement Arrangement (HRA) for your participation in the SmartHealth Wellness Program. You can use this health account to pay for your medical, prescription drug, dental and vision expenses. The HRA is designed to pay for your deductible and any other shared health care expenses.
- You may make contributions to the Health Care Flexible Spending Account. You may contribute as little as $260 or as much as $2,550 per year.
- If you contribute to a Healthcare Flexible Spending Account, any money in your FSA is used first. When you or a covered family member have health care expenses, your FSA may be used to pay your portion of the expense (copays, deductibles, coinsurance) until your FSA balance is used up. Then you may begin using the money in your HRA to pay for your portion of expenses.