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One of the more confusing aspects of insurance coverage is that of copays and deductibles. Though many patients are used to paying a fee when they see their medical provider it is often unclear why that fee is set at a certain amount and what that fee represents. The fee often seems inconsistent and some patients may feel that the provider has some influence over that fee and is not collecting it properly.


The fact is that Copays and Deductibles are two entirely different fees with different structures. In general, a copay is a set fee that insurance mandates you pay for a given medical service. For example, on the back of many of your insurance cards It might say $20 copay for medical visit. This means that if the visit costs $120.00 your insurance might reimburse the provider $100.00 and the patient pays $20. Or your card might say: Patient percentage 20%. So, if the visit cost $100 your copay is $20. Unfortunately, not all insurances publish copays on their cards. Nor do they inform the provider of their copay structure. It therefore falls on you, the patient, to have found that information in the fine print of your paperwork and know it by heart.


A deductible, on the other hand, is the amount you agreed to pay for medical services before your insurance kicks in. In general, the less expensive your insurance plan is the higher the deductible you agreed to. So, for example, if you come to see your primary care provider for a check up and have not yet met your $2000 deductible for the year, you are responsible for the full amount of the cost of that visit. You might pay $100 for a primary care visit vs the $20 copay because you have not yet personally spent $2000 for the year on your health care. Once you have met your deductible then your regular copays apply, and your visit may now be only $20.


The biggest misconception is that medical providers have anything to do with setting these copays and deductibles. In general, they do not. Unless the provider is taking cash only, he or she must follow the insurance company’s rules. This especially applies to practices that take Medicare like Eldorado Family Health. We are mandated to follow Medicare rules for billing and reimbursement.

The bottom line is that it is imperative that you investigate your insurance coverages carefully. Ask questions and be clear on what your financial responsibilities are so that there are no surprises. We here at Eldorado Family encourage you all to make informed decisions about your health insurance. Use an insurance broker who can explain these things to you, and find out which plans your preferred provide is allowed to take. Here is one website resource for health insurance information:

Let us be your primary care provider. Call and set up and appointment and establish care at (505-216-7772.

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