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%ages may differ. Refer to your Guide to Benefits for your specific copayment%ages.

Physician visit

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% of $80).

If you went to a nonparticipating physician, you’d owe a copayment of 30% 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% 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.

Surgical procedure — physician charge

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% of $40,000).

If you went to a nonparticipating provider, you’d owe a copayment of 30% 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% 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.