Patient Cost Estimates

The contracted rates between a Payer and Provider for services as defined in the Fee Schedule. “Allowable” can reference a specific code, type of service or the total of all services performed on the patient. Once the Allowable is calculated, then the patient portion is applied.

The fee a Provider charges for services performed. Charges are unique by each provider.

An insurance arrangement stipulating that the member is responsible for paying a specified percentage of any medical bills.

The insured patient’s share of the total medical bill, usually expressed as a specific dollar amount paid for a given service, product or treatment. For example, the patient might pay $10 for each visit to a doctor’s office, or $40 for hospitalization. The patient is usually responsible for payment at the time of treatment or service. The terms copayment and coinsurance are often used interchangeably despite their differences.

The portion of an individual’s healthcare expenses that must be paid by the member in a given year before the insurance plan will start paying for treatment.

The amount a member pays towards copays and coinsurance. Certain expenses may not apply to the out-of-pocket.

The amount the patient is responsible to pay for the services received. This amount includes disallowed charges, deductibles, copayments and coinsurance.

Most health plans must cover a set of preventive services, for example, shots and screening tests, at no cost to you. The health plan will either cover 100% of the cost for a preventive service up to a specific dollar amount or increase coinsurance percentage covered by the health plan