Copayment for a check up?

  • by ?
  • Jun 06,2018
  • 11 answers

My son’s doctor is out of network. He has a check up and is getting shots as well. I was told by his health insurance that they’ll cover it. It is when he gets sick that they will not. Is this right? Is it like this for most insurance companies? Just want to see if anyone has experienced this. If you have, did you pay for the office visit. I know I can just call again but I want to know what others say.


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Insurance Answers (11)

STEVEN F 2 months ago

You misunderstood EVERYTHING you told them, as well as what you think they told you.
The cover treatment for out of network doctors. They just pay LESS any you pay more.
In all likelihood, they pay the full amount of an annual checkup from an in network doctor, but require a copay for an out of network doctor. however, without SPECIFYING the plan you have, ANY answer about what is covered is an educated guess, because there is NO SUCH THING as terms that apply to ALL plans.

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? 2 months ago

No yes

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Insurance Pickle.com 2 months ago

Unlikely they'll pay for an out-of-network well visit. Highly unlikely that they'll pay for it in the same manner as in network.

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StephenWeinstein 2 months ago

For a healthy person, one checkup per year, vaccines, and birth control are fully covered, with no copayment. (For other types shots, such as allergy shots, antibiotics, painkillers, etc., you may have to pay.)
For a sick person, there is a copayment, typically (although this varies considerably) $5-75 for an office visit, 10%-50% for a hospital stay, and $50 to $600 for an ER visit without a hospital pay.

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lucy 2 months ago

As a general rule, if a doctor is in network, then the insurance will pay on average of 80%, but if out of network, then they may cover anywhere from 40% to 60% of the charges, meaning that YOU will have to pay the (difference) between the network vs the out of network charges.
So as an example the in network doctor would charge $100 for an office visit and the out of network charges $125 to $150. Your co-pay may apply to your deductible or (not).
I will give you a true example that happened to me about 10 years ago. I went to an out of network provider and had an exam and lab/blood tests done. The doctor charged me $90 and the lab costs were $413. My insurance in-network rate was $67 for exam and the lab was $187.
But since insurance would only consider the $67 and the $187, then I had to pay the difference of ($23 exam + $226 lab) out of my own pocket.
So it is not the issue if they cover or not, only that they will pay the (normal negotiated) rate of what a in-network charges, thus since out of network, then they have (no) agreement to charge you less, thus why they are out of network.
My suggestion is to see if you can find an in-network provider/doctor for your son (prior) to this visit so won't get any surprises of charges you might get stuck with.

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AJ 2 months ago

Why would you be taking him to a doctor that is out of network for? that is not a smart move. You need to be taking him to an in network doctor.

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Casey Y 2 months ago

If there is an available doctor in network...its crazy that they would pay for this. They might pay the out-of-network percentage...

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Flower 2 months ago

You always pay your co-pay whether insurance covers it or not, unless you have met your annual deductible. Your insurance said they will pay for an office visit but no treatment, is that what you mean?

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David 14 2 months ago

Every policy is different. You should check with your insurance company.

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K. Orrez 2 months ago

My insurance says I can go out of network if a doctor in the network is unavailable.

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don_sv_az 2 months ago

Get their statement that they will pay for the checkup in writing.

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