Healthcare Coverage & Patient Responsibility

Understanding the complexities of healthcare coverage and determining patient financial responsibility can be difficult, especially when medical services have yet to be determined.

As your community urgent care partner, we want to help guide our patients in understanding their financial responsibility. This includes copayment requirements or self-payment fees at the time of service and patient financial responsibility after services have been rendered, such as applied deductible amounts of covered or non-covered balances.

 

What is a Deductible?

The amount you pay for healthcare before your insurance starts to pay.

If you have a deductible of $2,500 and you undergo three $1,000 procedures in a year, you will pay the full bill for the first two procedures, $2,000, and $500 of the third. Your insurance will cover half of the third procedure, $500.

 

What is a Co-Pay?

A fixed dollar amount paid by the patient at the time of service.

The typical copay at urgent care is between $25 and $75, though this depends on your insurance. It’s the insurance company who sets the copay, not the urgent care center.

 

What is a Co-Insurance?

The percentage you must pay after you’ve met your deductible. This is similar to a copay but is expressed as a percentage rather than a fixed dollar amount.

Your health insurance plan’s allowed amount for an office visit is $100, and your co-insurance is 20%. If you have met your deductible, you pay 20% of $100 or $20.

 

What is Out of Pocket Maximum? (OOP)

The maximum amount you will pay after you have paid your copays, co-insurances, and deductibles.

If you have additional questions about your OOP please contact your insurance company, they will be better equipped to explain the details related to your plan.

 

What is an Explanation of Benefits? (EOB)

A statement sent by the insurance company explaining what medical treatments and/or services were paid for and what remaining balance the patient now owes to WellStreet.

Who receives an EOB? Once the claim has been processed by the insurance company, both the patient and WellStreet will receive an explanation of benefits.