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MAR Insurance Group
1534 W Contour Dr, #301
San Antonio, TX 78212

210-941-4054
Fax: 210-822-2325

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Copays? Coinsurance? How does this all work?

A simplified guide to how health insurance payments work for you, the insured.

Definitions

  • Co-pay: A specific dollar amount you pay for certain services (example Dr visit, Drugs). When the service has a co-pay the deductible does NOT apply.
  • Deductible: The amount of medical expense that you pay at 100% of cost.
  • Co-Insurance: The % of medical expense that you SHARE with the Insurance Company AFTER you have met your deductible. You pay this until you meet...
  • Max out-of-pocket: The most that you will pay for covered medical expense in a calendar year (Equals your deductible + co-insurance). After this is met, insurance pays 100% of covered costs.

Deductible and Co-Insurance Workflow (Slide 3)

Worst Case Scenario Example (Slide 4)

HMO is "Health Maintenance Organization"

  • You MUST choose a Primary Care Dr. in the HMO network
  • You MUST receive a written referral from their Primary Care Dr to a Specialist in the HMO network
  • The HMO network will have fewer Dr.’s
  • There are no benefits OUT OF NETWORK
  • Provides cost-effective access to care, especially for those with few needs

PPO is "Preferred Provider Organization"

  • You do not need to choose a Primary Care Dr.
  • You do not need a referral to a specialist
  • The PPO network will have the most Dr.’s
  • You may receive some (limited) benefits out of network
  • Offers the most freedom of choice at a higher cost per month

EPO is "Exclusive Provider Organization"

  • Much like a PPO, but with one crucial difference*
  • You do not need to choose a Primary Care Dr.
  • You do not need a referral to a specialist
  • The PPO network will have the most Dr.’s
  • You may receive some (limited) benefits out of network
  • Offers the most freedom of choice at a higher cost per month
  • *No out of network coverage

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