Calculating your PPO plan copayment
These examples show how HMSA calculates your copayment for covered services if your HMSA plan pays 90% of the eligible charge when you see a participating provider and 70% when you see a nonparticipating provider. Copayment percentages may differ. Refer to your Guide to Benefits for your specific copayment percentages.
When your copayment is 10% of the eligible charge for services from a participating physician and 30% for services from a nonparticipating physician:
You have a cold and go to a participating physician to have it checked out.
- The physician's bill or actual charge is $100.
- HMSA's eligible charge is $80.
- Your copayment is $8 (10 percent of $80).
If you went to a nonparticipating physician, you would owe a copayment of 30 percent of the eligible charge plus the difference between the eligible charge and the physician's actual charge. The nonparticipating physician may require payment of the actual charge at the time of service.
- The physician's bill or actual charge is $100.
- HMSA's eligible charge is $80.
- HMSA will reimburse you $56 (70 percent of $80).
- Your total out-of-pocket cost is $44.
| Physician | Physician's Actual Charge | Eligible Charge | Your Copayment | Calculation to Determine Your Portion of the Costs | Your Portion |
| Participating | $100 | $80 | 10% of eligible charge | $80 x 10% = $8 | $8 |
| Nonparticipating | $100 | $80 | 30% of eligible charge | $80 x 30% = $24
Difference between eligible charge and actual charge = $20
$24 + $20 = $44 | $44* |
*Note: Because services were provided by a nonparticipating physician, your physician may require payment of the actual charge of $100 and you may need to file your own claim.
When your copayment is 10% of the eligible charge for services from a participating physician and 30% for services from a nonparticipating physician:
You have a major surgical procedure done by a participating physician.
- The physician's bill or actual charge is $100,000.
- HMSA's eligible charge is $40,000.
- Your copayment is $4,000 (10 percent of $40,000).
If you went to a nonparticipating provider, you would owe a copayment of 30 percent of the eligible charge plus the difference between the eligible charge and the physician's actual charge. The nonparticipating physician may require payment of the actual charge at the time of service.
- The physician's bill or actual charge is $100,000.
- HMSA's eligible charge is $40,000.
- HMSA will reimburse you $28,000 (70 percent of $40,000).
- Your total out-of-pocket cost is $72,000.
| Physician | Physician's Actual Charge | Eligible Charge | Your Copayment | Calculation to Determine Your Portion of the Costs | Your Portion |
| Participating | $100,000 | $40,000 | 10% of eligible charge | $40,000 x 10% = $4,000 | $4,000 |
| Nonparticipating | $100,000 | $40,000 | 30% of eligible charge | $40,000 x 30% = $12,000
Difference between eligible charge and actual charge = $60,000
$12,000 + $60,000 = $72,000 | $72,000* |
*Note: Because services were provided by a nonparticipating physician, your physician may require payment of the actual charge of $100,000 and you may need to file your own claim.
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