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What Factors Affect Health Insurance Copay?

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  • Written By: Esther Ejim
  • Edited By: Kaci Lane Hindman
  • Last Modified Date: 05 September 2016
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    Conjecture Corporation
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There are many options for healthcare insurance with different implications for the particular choice of coverage and the circumstances of the individual applying for the health insurance coverage. The available health insurance plans are generally divided into three categories including the Health Maintenance Preferred Organization (HMO), a type of health insurance plan that only gives the insured the option of selecting a primary care physician from a predetermined pool of physicians who are already available on that particular insurance company’s network. Another type of health insurance plan is the Preferred Provider Organization (PPO), a plan that is less rigid than the HMO in the sense that it gives the insured individual the latitude to consult either a physician on the network of the insurance company or one who is not. The High Deductible Health Plan (HDHP) is even less restrictive than the other two in the sense that gives the insured the option of meeting a high deductible for both the prescription and the healthcare expenses, after which the insured will no longer be obliged to make any payments. It is the dynamics between these health plans in terms of their provisions that affect health insurance copay.

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The conditions in a HMO health insurance plan will affect health insurance copay in the sense that there is usually a fixed predetermined copay for utilizing any health service under this plan. This exact rate of the copay is determined by the insurance company in question. Such plans usually charge different copays for seeing different types of physicians under the plan, even if they are within the health insurance network. As such, the copay for a primary care doctor will differ from the copay for maternity care.

Under the PPO plan, the factors that affect health insurance copay are also specific to the health insurance company and the provisions for the various plans. In this particular health plan, the choice of either seeing a physician within the insurance network or outside the network attracts different copay rates. Consulting a physician outside the network usually leads to a copay rate that may be calculated at 40 percent of the total cost incurred.

In the case of the HDHP plan, the factors that affect health insurance copay are different since the insured will not be obliged to make any copays as a result of any of the approved health services until he or she has met the deductible. There are some circumstances, however, in which the person may be required to pay the difference of the balance and be denied reimbursement respectively. For example, the person may exceed the allowed amount for a procedure or engage in some procedures without obtaining permission first.

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