“But I Paid My Copay!”

Sep 20, 2017 | Robert McGriff | @m039153 | Comments (1)


It seems simple enough but the copay is actually an often misunderstood part of the medical plan.

Most covered items in the Mayo Medical Plan are paid following a pretty simple model. First, you are responsible for your annual deductible.  Once that has been met, the plan begins to share the cost of medical services with you, paying 80% for in-network claims.  If your prescription costs and your deductible and your 20% amounts add up to the out-of-pocket (OOP) maximum for your plan and coverage level, then the plan will pay 100% of approved, in-network claims for the remainder of the calendar year.  Those are the basics.

But the copay is an exception to this process. In Mayo Premier and Mayo Select, primary care, urgent care and emergency room visits have a copay amount.  That means that you can expect to pay a fixed amount (or the copay could be $0) for that service, usually when you walk in the door.

Here’s where it can be confusing. After the visit, you may still receive a statement showing that you are responsible for additional amounts.  You may find yourself saying “But I paid my copay!”  The fact is that the copay you paid covers the facility charge for that episode of care.  But, there could be other charges for laboratory, radiology or a minor procedure performed during the visit.  Those items would fall back into the standard payment model of deductible>20%>OOP maximum.  Before you call Customer Service, review the charges and payments.  In most cases, the claim has processed correctly and you probably owe a balance.  If you still think something is not right, feel free to reach out to Mayo Clinic Health Solutions at 1-800-635-6671.

Thanks for the clear explanation!

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