- Preferred Provider Organization (PPO) is a health plan that offers a large network of participating providers so you have a range of doctors and hospitals to choose from. If you choose a PPO health plan, it’s important to know.
- $0 copay $40 copay $0 copay Specialist $35 copay 40% of the cost $0 copay Preventive Care With Medicare only In. Humana is a Medicare Advantage PPO plan with a Medicare contract. Enrollment in this Humana plan depends on contract renewal.
- As a member of our PPO, Plus PPO or Premier PPO plan, you can choose to receive care from out-of-network providers. These plans will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary.
. When using Non-PPO and Other Health Care Providers, members are responsible for any difference between the covered expense '&' actual charges, as well as any deductible '&' percentage copay. Additional visits maybe authorized if medically necessary. Pre -service review must be obtained prior to receiving the additional services.
It is important to understand how your health care plan operates, but far too often the tricky benefit jargon of “deductible, coinsurance, copay, and out-of-pocket max” get in the way. These hard to understand health care vocabulary terms are explained below to help make understanding your health care plan much simpler!
Deductible – the amount of out-of-pocket expenses you pay for covered health care services before the insurance plan begins to pay.
| HSA-Eligible Plan | All covered services require you to meet your deductible first and then services will be covered through coinsurance. |
| PPO Plan | Some covered services require you to meet the deductible first, while other covered services are paid with a copay. |
| Helpful Hint! | The health plan comparison chart shows deductible amounts for Tier 1, Tier 2 and Tier 3, but you should think of your deductible as one sum of the money you have paid for your services. |
| Example | With a $1500 Tier 1 deductible on the HSA-Eligible Plan with single coverage, you pay the first $1500 of covered services yourself. If you have met this, you would pay an additional $100 towards your services and then would have met the Tier 2 deductible of $2,500. |
Coinsurance – the percentage of cost of a covered health care service you pay once you have met your deductible.
| HSA-Eligible and PPO Plans | For services covered by “coinsurance after deductible” the amount you pay in co-insurance continues to count towards meeting your next Tier deductible. |
| Coinsurance % | Most Tier 1 services are covered at “90% coinsurance after deductible,” while Tier 2 services are “75% after deductible and Tier 3 are “60% after deductible.” |
| Example | If you are on either plan and have hit your Tier 1 deductible and visit a Tier 1 urgent care provider, the plan covers that service at “90% coinsurance after deductible.” This means you will pay 10% of the cost of the visit and your insurance will cover the remaining 90%. The 10% you pay will count towards your deductible. |
Copay – a fixed dollar amount you must pay to a provider at the time services are received.
| PPO Plan | Only the PPO Plan offers a copay option for specific covered services. Your copay does not count towards your deductible. |
| Copay Amounts | Copay amounts vary based on the plan design. The health plan comparison chart is the best resource to understand what your copay is for a covered service within any of the tiers. |
| Example | If you are on the PPO plan and you see a Tier 1 provider for a standard sick visit, then your copay at the time of the visit will be $20. If you seek a Tier 1 provider for physical therapy, then your copay will be $35. |
Out-of-Pocket Max – the maximum amount you pay each calendar year to receive covered services after you meet your deductible. Once you meet your out-of-pocket maximum, the Plan pays 100% of covered services you receive. In network and out-of-network services are subject to separate out-of-pocket maximums.
| HSA-Eligible and PPO Plans | Your out-of-pocket max is the summation of everything you have paid for your medical services received; this includes deductible, coinsurance and copay. |
| Helpful Hint! | Out-of-pocket max’s are determined by coverage level (single vs plan with dependents) and salary. On the health plan comparison chart you will see multiple rows with Out-of-Pocket Max figures, so be sure to look in the row that pertains to your situation. |
These examples show how HMSA calculates your copayment for covered services if your HMSA plan pays 90% of the eligible charge when you see a participating provider and 70% when you see a nonparticipating provider. Copayment%ages may differ. Refer to your Guide to Benefits for your specific copayment%ages.
Physician visit
When your copayment is 10% of the eligible charge for services from a participating physician and 30% for services from a nonparticipating physician:
You have a cold and go to a participating physician to have it checked out.
- The physician’s bill or actual charge is $100.
- HMSA’s eligible charge is $80.
- Your copayment is $8 (10% of $80).
Ppo Copays
If you went to a nonparticipating physician, you’d owe a copayment of 30% of the eligible charge plus the difference between the eligible charge and the physician’s actual charge. The nonparticipating physician may require payment of the actual charge at the time of service.
- The physician’s bill or actual charge is $100.
- HMSA’s eligible charge is $80.
- HMSA will reimburse you $56 (70% of $80).
- Your total out-of-pocket cost is $44.
| Physician | Physician’s Actual Charge | Eligible Charge | Your Copayment | Calculation to Determine Your Portion of the Costs | Your Portion |
|---|---|---|---|---|---|
| Participating | $100 | $80 | 10% of eligible charge | $80 x 10% = $8 | $8 |
| Nonparticipating | $100 | $80 | 30% of eligible charge | $80 x 30% = $24 Difference between eligible charge and actual charge = $20 $24 + $20 = $44 | $44* |
*Note: Because services were provided by a nonparticipating physician, your physician may require payment of the actual charge of $100 and you may need to file your own claim.
Surgical procedure — physician charge
When your copayment is 10% of the eligible charge for services from a participating physician and 30% for services from a nonparticipating physician:
You have a major surgical procedure done by a participating physician.
- The physician’s bill or actual charge is $100,000.
- HMSA’s eligible charge is $40,000.
- Your copayment is $4,000 (10% of $40,000).
If you went to a nonparticipating provider, you’d owe a copayment of 30% of the eligible charge plus the difference between the eligible charge and the physician’s actual charge. The nonparticipating physician may require payment of the actual charge at the time of service.
- The physician’s bill or actual charge is $100,000.
- HMSA’s eligible charge is $40,000.
- HMSA will reimburse you $28,000 (70% of $40,000).
- Your total out-of-pocket cost is $72,000.
| Physician | Physician’s Actual Charge | Eligible Charge | Your Copayment | Calculation to Determine Your Portion of the Costs | Your Portion |
|---|---|---|---|---|---|
| Participating | $100,000 | $40,000 | 10% of eligible charge | $40,000 x 10% = $4,000 | $4,000 |
| Nonparticipating | $100,000 | $40,000 | 30% of eligible charge | $40,000 x 30% = $12,000 Difference between eligible charge and actual charge = $60,000 $12,000 + $60,000 = $72,000 | $72,000* |
Aetna Medicare Ppo Copay
*Note: Because services were provided by a nonparticipating physician, your physician may require payment of the actual charge of $100,000 and you may need to file your own claim.