 Member Handbook New PCP Request Member Handbook POS Products Healthy New York Benefit Summaries Riders Rx Plans Member FAQ Member Newsletter HIPAA Information Forms Contact Us | |
| |
Co-Payments, Coinsurance, and Deductibles
A. CO-PAYMENTS
When using In-Plan benefits, you will be responsible for co-payments for certain professional and/or institutional services. A co-payment is a portion of the cost of the service that you are responsible for at the time the service is received.
Co-payments for professional services apply to most "visits" to a physician or other provider. The amount of the co-payment is based upon the benefit plan in which you are enrolled and the medical service received. Co-payments are on a "per visit" basis so that a visit to a provider that involves more than one service, for example, a visit to an OB/GYN that involves lab tests, will only be subject to a single co-payment.
Co-payments are not applicable to services that do not involve a visit, for example, ambulance and durable medical equipment.
Co-payments for inpatient hospital services are per "continuous confinement". A continuous hospital confinement means consecutive days as an inpatient, or successive confinements when discharge and readmission occurs within a period of not more than 90 days.
Please see the "SUMMARY OF BENEFITS" for co-payment amounts that apply to specific services.
B. DEDUCTIBLES
When accessing out-of-Plan (POS) benefits, you will be financially responsible for a certain accumulated amount in Covered Services before Atlantis begins claims payments.
Deductibles are per calendar year and apply to all enrollees in the Group Contract. Deductible credits from a previous contract cannot be applied to this coverage. Expenses incurred in the last three months of a calendar year may not be �carried over�.
The amount of the deductible varies by contract. For example, if the calendar year deductible is $500 per individual and $1,250 per family: When one family Member accrues $500 in Covered Services, benefits are payable only for that family Member for the expenses in excess of $500. If the combined Covered Services of all family Members are in excess of $1,250, benefits are then payable for all family Members even if no one Member of the family has incurred more than $500 in covered expenses.
C. COINSURANCE
When using out-of-Plan (POS) benefits, you will be financially responsible for a percentage of the service after reaching your deductible. This cost-sharing arrangement is called coinsurance. For example, if your coinsurance is 20%, Atlantis will pay 80% of the approved amount and you will be responsible for the balance. Payment would be calculated as follows:
Provider Service Charge $300
Approved UCR $250
Atlantis Payment (80% of UCR) $200
Member Responsibility $100
This example assumes that the calendar year deductible was previously met.