$0 virtual care benefit not available for all plans in AZ and CO. Some plans may apply a copay, coinsurance or deductible. Virtual care does not guarantee that a prescription will be written. Refer to plan documents for complete description of virtual care services and costs, including other telehealth/telemedicine benefits. Coinsurance is your share of the costs of a health care service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you've paid your plan's deductible. How it works: You’ve paid $1,500 in health care expenses and met your deductible. When you go to the doctor, instead of paying all costs, you and your plan share the cost. Copay plans include: Copays – for basic services like preventive exams, telemedicine and pharmacy Virtual visits with board-certified doctors – 24/7, with Doctor On Demand Go365® rewards for healthy behaviors – like Target and Amazon gift cards.
A copayment or copay is a fixed amount for a covered service, paid by a patient to the provider of service before receiving the service. It may be defined in an insurance policy and paid by an insured person each time a medical service is accessed. It is technically a form of coinsurance, but is defined differently in health insurance where a coinsurance is a percentage payment after the deductible up to a certain limit. It must be paid before any policy benefit is payable by an insurance company. Copayments do not usually contribute towards any policy out-of-pocket maxima whereas coinsurance payments do.[1]
Insurance companies use copayments to share health care costs to prevent moral hazard. It may be a small portion of the actual cost of the medical service but is meant to deter people from seeking medical care that may not be necessary (e.g., an infection by the common cold). In health systems with prices below the market clearing level in which waiting lists act as rationing tools,[2] copayment can serve to reduce the welfare cost of waiting lists.[3]
However, a copay may also discourage people from seeking necessary medical care and higher copays may result in non-use of essential medical services and prescriptions, thus rendering someone who is insured effectively uninsured because they are unable to pay higher copays. Thus, there is a balance to be achieved: a high enough copay to deter unneeded expenses but low enough to not render the insurance useless.[editorializing]
Germany[edit]
The German healthcare system had introduced copayments in the late 1990s in an attempt to prevent overutilization and control costs. For example, Techniker Krankenkasse-insured members above 18 years pay the copayments costs for some medicines, therapeutic measures and appliances such as physiotherapy and hearing aids up to the limit of 2% of the family's annual gross income. For chronically ill patients, the co-payment limit is 1% including any dependant living in their home. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).[4][5] The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[6] However, after research studies by the Forschungsinstitut zur Zukunft der Arbeit (Research Institute for the Future of Labor) showed the copayment system was ineffective in reducing doctor visits, it was voted out by the Bundestag in 2012.
Prescription drugs[edit]
Some insurance companies set the copay percentage for non-generic drugs higher than for generic drugs. Occasionally if a non-generic drug is reduced in price insurers will agree to classify it as generic for copayment purposes (as occurred with simvastatin). Pharmaceutical companies have a very long term (frequently 20 years or longer) lock on a drug as a brand name drug which for patent reasons cannot be produced as a generic drug. However, much of this time is exhausted during pre-clinical and clinical research.[7]
To cushion the high copay costs of brand name drugs, some pharmaceutical companies offer drug coupons or temporary subsidized copayment reduction programs lasting from two months to twelve months. Thereafter, if a patient is still taking the brand name medication, the pharmaceutical companies might remove the option and require full payments. If no similar drug is available, the patient is 'locked in' to either using the drug with the high copays, or a patient takes no drugs and lives with the consequences of non-treatment.
Observed effects[edit]
How To Calculate Copay
Medication copayments have also been associated with reduced use of necessary and appropriate medications for chronic conditions such as chronic heart failure,[8]chronic obstructive pulmonary disease, breast cancer,[9] and asthma.[10] In a 2007 meta-analysis, RAND researchers concluded that higher copayments were associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy.[11]
See also[edit]
Notes[edit]
- ^University of Puget Sound. Benefits update. 2006 medical plan frequently asked questions. What is the difference between co-payments, coinsurance, and deductibles? Retrieved November 10, 2008.
- ^Lindsay, Cotton M. and Bernard Feigenbaum (1984) 'Rationing by waiting lists', American Economic Review 74(3): 404-17.
- ^Diego Varela and Anca Timofte (2011), 'The social cost of hospital waiting lists and the case for copayment: Evidence from Galicia'Archived 2015-11-07 at the Wayback Machine, The USV Annals of Economics and Public Administration 11(1): 18-26.
- ^'Germany: Health reform triggers sharp drop in number of hospitals'. Allianz. 25 July 2005. Retrieved November 14, 2011.CS1 maint: discouraged parameter (link)
- ^'Average Length of Hospital Stay, by Diagnostic Category – United States, 2003'. Centers for Disease Control and Prevention. Retrieved November 14, 2011.CS1 maint: discouraged parameter (link)
- ^Borger C, Smith S, Truffer C, et al. (2006). 'Health spending projections through 2015: changes on the horizon'. Health Aff (Millwood). 25 (2): w61–73. doi:10.1377/hlthaff.25.w61. PMID16495287.
- ^Schacht, Wendy H. and Thomas, John R. Patent Law and Its Application to thePharmaceutical Industry: An Examination of the Drug Price Competition and Patent Term Restoration Act of 1984('The Hatch-Waxman Act')[1] Retrieved December 1, 2014.
- ^Cole JA, et al. Drug copayment and adherence in chronic heart failure: effect on cost and outcomes.[permanent dead link] Pharmacotherapy 2006;26:1157-64.
- ^Neugut AI, Subar M, Wilde ET, Stratton S, Brouse CH, Hillyer GC, Grann VR, Hershman DL (May 2011). 'Association Between Prescription Co-Payment Amount and Compliance With Adjuvant Hormonal Therapy in Women With Early-Stage Breast Cancer'. J Clin Oncol. 29 (18): 2534–42. doi:10.1200/JCO.2010.33.3179. PMC3138633. PMID21606426.[permanent dead link]
- ^Dormuth CR, et al. Impact of two sequential drug cost-sharing policies on the use of inhaled medications in older patients with chronic obstructive pulmonary disease or asthma. Clin Ther 2006;28:964-78; discussion 962-3.
- ^Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA 2007;298:61-69.
Carriers
BlueCross BlueShield of Tennessee
800.558.6213
Monday - Friday, 7 - 5 CT
bcbst.com/members/tn_state/
Cigna
800.997.1617
24/7
cigna.com/stateoftn
Members can request additional ID cards by contacting their carrier or by using the carrier’s mobile app. Employees new to coverage, or who change or transfer plans, will receive new ID cards.
For more health insurance carrier network information, visit the Carrier Information page.
Health insurance options
Partners for Health offers three health plans for state and higher education members and four health plans for local education and local government members. Use the arrows below to see what health plans are available to you.
Health insurance options for:
Premier PPO
Higher premiums― but lower out-of-pocket costs for your deductible, copays and coinsurance.
Standard PPO
Lower premiums than the Premier PPO― but you’ll pay more out-of-pocket for your deductible, copays and coinsurance.
CDHP/HSA
Lowest premiums―but you pay your deductible first before the plan pays anything for most services, and then you pay coinsurance, not copays. Go to the CDHP/HSA page to learn more.
Premier PPO
Higher premiums― but lower out-of-pocket costs for your deductible, copays and coinsurance.
Standard PPO
Lower premiums than the Premier PPO― but you’ll pay more out-of-pocket for your deductible, copays and coinsurance.
Limited PPO
Lower premiums than the other PPOs―but you’ll pay more out-of-pocket for deductible, copays and coinsurance compared to the other PPOs.
Local CDHP/HSA
Lowest premiums―but you pay your deductible first before the plan pays anything for most services, and then you pay coinsurance, not copays. Go to the CDHP/HSA page to learn more.
Each healthcare option has different cost sharing — cost sharing is your out-of-pocket costs for copays, deductibles, coinsurance and out-of-pocket maximums.
For all options, preventive care is free if you use an in-network provider (see Wellness page for details). All healthcare options cover the same services and treatments, but medical necessity decisions may vary by carrier.
How do I receive services covered by the “Barry Brady Act”?
If you are a firefighter who qualifies for additional health screenings under the Barry Brady Act and your related claims process with unexpected member cost share call your health insurance carrier’s customer service number and request a reconsideration of your claims.
Need information on behavioral health? Behavioral health benefits are provided by Optum. Click here to go to the behavioral health page.
| CDHP | Consumer-driven health plan, a type of medical insurance or plan that generally has a higher deductible and lower monthly premiums. Typically, you take responsibility for covering your health care expenses until your deductible is met. Once you meet your deductible, coinsurance applies up to the out-of-pocket maximum. |
| Coinsurance | Some services require that you pay coinsurance. Coinsurance is a percentage of the total cost. |
| Deductible | All options include an annual deductible. You pay this amount out of pocket before the plan pays for most services that require coinsurance. |
| Cost Sharing | The share of costs not covered by your insurance that you pay out of your own pocket. |
| Copay | Some services require that you pay a copay. A copay is a flat dollar amount, like $25 for a doctor's visit. |
| Network | A group of doctors, hospitals, facilities and other healthcare providers contracted with a health insurance carrier to provide services to plan members for set fees. |
| Out-of-Pocket Maximum | The out-of-pocket maximum is the most you will pay for your copays, deductible and coinsurance each year. Once you reach your out-of-pocket maximum, the plan pays 100% of covered medical expenses. |
| In-Network vs. Out-of-Network Providers | You can see any doctor or go to any healthcare facility you want. However, if you use an 'in-network' provider, you will always pay less. That's because an in-network provider agrees to provide services at discounted rates. |
| Plan | The State of Tennessee Group Insurance Program, including state-sponsored PPO and CDHP/HSA plan options. The plan provides or pays a portion of the cost of medical care and determines how much you pay in premiums, copays and coinsurance. |
| PPO | Preferred provider organization, gives plan participants access to a network of doctors and facilities that charge pre-negotiated (and typically discounted) fees for the services they provide to members. The benefit level covered through the plan depends on whether the member visits an in-network or out-of-network provider when seeking care. |
For more detailed information, member handbooks are available on the Publications page.
Medical service appeals
Copay Health Insurance Plans
If you are a plan member in disagreement with a decision or the way a claim has been paid or processed, you or your authorized representative should first call member services to discuss the issue: BlueCross BlueShield of Tennessee 800-558-6213 or Cigna 800-997-1617.
First Level Appeal — If the issue cannot be resolved through member services, you or your authorized representative may file a formal request for internal review or member grievance. All requests must be filed within the stated timeframes. When your request for review or member grievance is received, you will get a letter about what to expect regarding the processing of your grievance. Once a decision is made, you will be notified in writing. You will be advised of any further appeal options including information about how to request an external review of your case from an independent review organization (IRO).
Second Level Appeal — If the first level appeal is denied, you or your authorized representative may file a second formal request for internal review or member grievance. All requests must be filed within the stated timeframes. When your request for review or member grievance is received, you will get a letter about what to expect regarding the processing of your grievance. Once a decision is made, you will be notified in writing. You will be advised of any further appeal options including information about how to request an external review of your case from an independent review organization (IRO).
External Review — If your first and/or second level internal appeal is denied, you or your authorized representative may choose to request that an IRO review the case. The IRO will make a final decision. The IRO will communicate their decision to you. This decision will be final and binding on you, the plan and the carrier.
The appeals/grievance form can be found at www.bcbst.com/members/tn_state or www.cigna.com/sites/stateoftn/index.html. Members will have 180 days to begin an internal appeal after a notice of an adverse decision. Notification of decisions will be made within the following time frames and all decision notices shall advise of any further appeal options:
All Copay Health Insurance Plans
- No later than 72 hours after receipt of the appeal for urgently needed services
- 30 days for denials of non-urgent care not yet received
- 60 days for denials of services already received