Confused about Empire Plan copayments? Here’s some help
By LORRAINE SIMPKINS PEF members enrolled in the
state’s Empire Plan often are unsure how many copayments they might be required to pay during a single visit to a participating physician. A copayment is a specific dollar amount paid by the enrollee for a covered service, such as $20 for a physician office visit. For Empire Plan enrollees, services
covered under the Medical Program that require a copayment are classified into four basic categories: office visit, office surgery, laboratory service, and radiology service. In general, one copayment
is due for any one service or multiple services within each category during a single visit. This would result in a
maximum of four copayments per visit. However, the 2011-2015 PS&T Contract limits the number of copayments per visit as follows: • Only one copayment will be due for an office visit and office surgery on the same date; and • Only one copayment will be
due when laboratory and radiology
services are performed on the same date. This results in a maximum of two
copayments per visit to the same physician. However, if your physician collects
a specimen or sample during a visit and then sends it to another participating provider for analysis, it generates a separate bill from a different provider. One copayment will be due for this service resulting in three copayments on the same date. Participating physicians can
require you to make all of the copayments at the time of service. If the Empire Plan’s allowance is less than the required copayment amount, you will pay the lesser amount. For example, if the allowance for a lab test were $10, you would pay $10, instead of the standard $20 copayment. Certain services are excluded from
copayment requirements under the Empire Plan. Services not subject to a copayment are: allergy immunizations, allergy serum, chemotherapy, hemodialysis, prenatal care, radiation therapy, well child care and services defined as “preventive services” by the federal Patient Protection and Affordable Care Act (PPACA), also known as “Obamacare.” For a complete list of preventive
screenings and services not subject to a copayment, go online to
www.healthcare.gov.
Page 20—The Communicator March 2014
PEF Information Line: 1-800-553-2445
HEALTH NOTES
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