What is Cost share and Collection process

What is Cost Sharing?

Cost sharing is the patient balance that remains after the insurance plan has applied payment for  covered services according to the benefit plan.

Your share of costs for services that a plan covers that you must pay out of your own pocket (sometimes called “out-of-pocket costs”). Some examples of cost sharing are copayments, deductibles, and coinsurance. Family cost sharing is the share of cost for deductibles and out-of-pocket costs you and your spouse and/or child(ren) must pay out of your own pocket. Other costs, including your premiums, penalties you may have to pay, or the cost of care a plan doesn’t cover usually aren't considered cost sharing.

Member Cost-sharing

Deductibles, coinsurance and copayments are the member’s contribution toward all services. As a participating provider, you have agreed to not waive these amounts. When the charge for an office visit is less than the member’s copayment, providers should collect the actual charge. If you collect any amount above the copayment for covered services, you must refund the member the excess amount collected within 30 days of notification of the overpayment.

Participating providers have also pledged to assist us in our efforts to keep our members’ costs down. Please be aware that members could pay higher copayments for certain covered services performed by different types of providers and facilities. The chart below illustrates an example situation of how a member’s cost share will increase if they go to an outpatient facility for services that may be performed at an in-network physician’s office, in-network independent lab or free-standing diagnostic imaging facility:

Cost-sharing Reductions

Discounts that reduce the amount you pay for certain services covered by an individual plan you buy through the Marketplace. You may get a discount if your income is below a certain level, and you choose a Silver level health plan or if you're a member of a federally recognized tribe, which includes being a shareholder in an Alaska Native Claims Settlement Act corporation.

What does it include?

Cost Sharing includes:



A fixed amount you pay for a covered health care service , to be paid when you receive the service

The amount can vary by the type of covered health care service.
$15 primary care
$25 specialist


The amount the patient owes for healthcare services before your health insurance plan begins to pay
Deductible may not apply to all services
Deductibles are applied annually


Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service

Co-insurance plus deductible may apply in some cases

Cost Sharing Tools

Most commercial Health Insurance carriers have cost estimators on their websites to help you estimate your out-of-pocket expense.

Calculate your estimated costs for procedures, office visits, lab tests, and surgeries.
Compare what your cost sharing will be at different providers and locations.

Medicare Cost Comparison

Medicare also provides transparency into healthcare costs on their website You can compare hospital pricing for hospital inpatient and outpatient care The annual Medicare and You booklet also provides insight into Medicare covered benefits

Visit the Medicare website: www.medicare.gov

Pre-Collection Process

You will receive 3 statements before balances are flagged at collect status

Statement messages indicate the aging of your statement balance

Statement Messages

Second Statement:
Your account is overdue; please pay this balance immediately.

Third Statement:
Your account is in collections status; please contact the office immediately.

Collection Letters

You will receive a separate letter from Insurance company when your balance is billed on a second and third statement.

The letter is to remind you that your account is in collect status and if the balance is not paid it will go to our outside collection agency.

Collection Policy

Insurance company  does send aged balances to a collection agency.

Insurance company  has contracted with Collection Agency to help us recover unpaid patient balances.

Account balances are sent to the collection agency after you receive 3 statements and you do not make a payment.

What to Expect from the Collection Agency

Patient receives automated and live calls from the agency. Collection balance is not reported to the credit bureau until 90 days after placement with the agency.

Payments can be made directly to Agency or to Insurance company . Agency will update Insurance company records to show your payment was made and clear your balance.

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