What is the difference between deductibles and co-payments?
A12: A calendar year deductible is the amount of covered medical expenses an individual pays each calendar year before benefits are paid by the plan. A co-payment is the fee charged by a health care professional to an individual for a covered medical expense or for covered prescription drug expenses.
A41. Co-payment is a type of member cost sharing that requires a flat amount per unit of service or unit of time. This is usually a percentage of the charges but may also be a dollar amount for specified services. The most common percentage co-payment is 20%. Deductible is an amount the insured person must pay before insurance payments for covered services begin. The deductible is usually a set amount or a percentage determined by the member’s contract, and is calculated based on the lower of the hospital/provider actual charges or the payment benefit. For example, an insurance plan might require the insured to pay the first $250 of covered expenses during a calendar year.
