Why am I being asked to pay for a covered treatment?

Most health plans make their members pay deductibles, copays, and/or coinsurance.

• A deductible is an amount a patient pays for covered treatments or medicines before the health plan starts paying for them.
• A copay is a fixed amount that a patient pays for each health care service. For example, a health plan may have their members pay $5 for most prescriptions and the plan covers the rest of a drug’s cost. Tip: Copays count toward the out-of-pocket maximum but usually not the deductible.
• Coinsurance is the percent of a charge patients pay after they've met their deductible. For example, members of some health plans pay 20% of the total and the health plan pays the rest. There is usually a maximum amount members pay during a year (often called the “out-of-pocket maximum”). After that, the plan pays 100%.

OHA hears from people who were told a treatment was covered but were billed because they hadn’t paid their deductible yet. If you think the insurer should have paid the amount, we can:

• Help you confirm your benefits were properly applied
• Work with your health plan if the benefits were not properly applied