Copays + Deductibles + Coinsurances = MOOP Page 2 of 7
COPAY
A fixed dollar amount that you pay for a covered medical service, like going to the doctor or paying a fixed copay for a generic
prescription.
- $30 copay for a primary doctor's office visit
- $60 copay for a specialist visit
- $15 copay for a generic prescription
DEDUCTIBLE
Your deductible is the amount you pay before your insurance plan starts to pay. If your health plan has $3,000 deductible, then you would pay the 1st $3,000 in
covered services - at the negotiated rate. Once your deductible is paid, future services would be either a copay, coinsurance or covered at 100%.
COINSURANCE
This is called "splitting the bill". You and the carrier split the bill for certain covered services.
ie. surgeries, testing or hospitalizations, etc..
- 50/50: Carrier pays 50% ---> Member pays 50%
- 80/20: Carrier pays 80%, ---> Member pays 20%
MAXIMUM OUT OF POCKET - MOOP
- Your copays, deductible charges and coinsurance payments for all covered services go towards your MOOP, including prescriptions.
- Once you reach your MOOP, you will be covered at 100% for the rest of the year for covered medical services as well as covered
prescriptions.
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