Healthcare coverage in America is complicated, and it can be difficult to understand what exactly your medical insurance covers (and what you’ll be responsible for paying). Let us explain the basics of insurance to help you make more informed healthcare decisions and avoid surprise bills.

In-Network vs Out-of-Network

When deciding where to go, it’s important to choose an in-network healthcare provider. An in-network provider has a contract with your insurer to provide services to plan members for specific pre-negotiated (i.e. discounted) rates, this is often called contracted insurance.

Out-of-network providers have not agreed to these rates, and as the patient, you’ll likely end up paying a lot more. The phrase accepted insurance only means the provider will file the claim on your behalf and does not necessarily mean that they are contracted as “in network” with your insurer.

Gateway Family & Urgent Care participates in many major insurance networks. Contact your insurer to confirm coverage.

Deductible

A deductible is the amount you pay each year for eligible medical services or medications before your insurance plan kicks in. If you have a $1,500 annual deductible, you’ll need to pay the first $1,500 of your eligible medical costs.

Many medical costs are eligible to count towards your deductible, such as bills for hospitalization, surgery, MRIs, CAT scans, lab tests, and anesthesia. However, costs for things like well visits, copays and your insurance premium generally do not count towards the deductible.

If you haven’t yet met your yearly deductible, your insurance company will not pay the claim for your visit, and you will be responsible for the total cost.

Copays

A copay is a fixed amount you pay for a particular health care service, usually at the time of service. Copay amounts can be found right on the front of your insurance card.

When you arrive to an appointment at Gateway Family & Urgent Care, show your insurance card to the front desk and be prepared to pay your copay. Please be aware that a copay for an urgent care visit may be higher than a primary care appointment. Check out our helpful decision guide to decide which kind of appointment is right for you.

There may be additional out-of-pocket costs after your copay. Lab work done off-site is billed separately, and your insurance may only cover a portion of the services during the visit. Learn more about how claims are processed below.

How Claims Work

After your visit, the healthcare provider will file a claim with your insurance company, outlining the specific care and services you received during the visit. Your insurance provider will review this claim, and determine the cost –or allowed amount– of the visit. The allowed amount is the maximum amount a plan will pay for a covered health care service.

The insurance company will send your healthcare provider a summary detailing how much they will pay, and how much you, the patient, owes. You will also receive an Explanation of Benefits, which explains how costs are shared.

Once your healthcare provider receives the insurance company’s payment, they will send you a bill for the remaining cost of the visit. This bill, for which you are responsible, will go toward your deductible or coinsurance, and should be paid directly to the healthcare provider. Many healthcare providers will work with you on payment plans if you can’t pay in-full by the given due date.

Still have questions about health insurance and billing?

Give us a call – (408) 364-7600

Gateway Family and Urgent Care

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