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Understanding Who Pays for What


Almost everyone receives, at least once, an unexpected bill in the mail. Whether the amount is large or small, if you weren’t expecting it, it is an unpleasant surprise. Presbyterian Health Plan wants your insurance experience to be surprise-free, so we’ve provided this information to help you understand what to expect.

The First and Best Place for Information

Your Member Benefits Handbook is first place to go to find out what to expect when it comes to what you can expect to pay for services. A quick summary of the benefits is often included in the Benefits Summary, sometimes called the Schedule of Benefits. These documents, along with the Subscriber Agreement, are the legal agreement between you and your insurer. If you have any questions about a specific plan or specific coverage, please contact Presbyterian Health Plan’s Customer Service Center at:

TTY: 1-877-298-7407

General Patient Costs

Healthcare costs are generally shared costs – the patient pays some of the expense, but so does the insurance company, the healthcare organization, and your employer (if you have insurance through your employer) or the government (if you have Medicaid or Medicare). As a patient, you may only see your part of the expense – and that falls into a few areas:

  • Premiums. Premiums are the payments you make, generally each month, to participate in the plan. Premiums are sort of the way you continue your subscription to your insurance plan. If you don’t play your premiums, your insurance “subscription” is cancelled.
  • Copays. Copays (sometimes called copayments) are the amount the patient pays for a specific visit or procedure. Generally, you can expect to pay something every time you see a doctor. Your copay is usually a very small amount compared to the total cost of that office visit.
  • Deductibles. Deductibles are the amount of money you pay to cover your healthcare costs before insurance starts paying. For example, if your deductible is $2,500 a year, you need to pay that amount – for lab tests and procedures and other care – before insurance starts paying. Generally, premiums and copays do not count toward your deductible.
  • Limits. Some insurance plans limit the amount of coverage you can get in a year for a specific treatment. For example, imagine you wanted to have dental work done that was estimated to cost $1,200. Your deductible is $500, and your annual limit is $500. You can expect to pay $700 of the bill -- $500 for the deductible, and $200 for the amount over the limit.
  • Labs and Specialists. Sometimes your doctor will order a test or procedure that requires the time and talents of people you never see. A specialist might read your test results, after a lab has processed them. Sometimes the cost of these “hidden” specialists isn’t completely covered, and you’ll receive an unexpected bill.

Ways to Keep Your Expenses Down:

  • Pick the Right Plan. Choose a plan that best meets the needs of you and your family.
  • Stay In-Network. Network doctors have agreed to be paid specific amounts that keep the costs down for you and the insurance company.
  • Stay Healthy. Preventive care is less expensive for everyone, and you don’t have to spend a week with the sniffles.
  • Go Generic. Unless your doctor says there is a reason not to, choose the generic equivalent of your prescription (if there is one). Generic drugs are regulated by the FDA and have the same active drug ingredients, safety, performance, quality, and strengths as brand name drugs. Consult with your doctor or pharmacist if a generic equivalent is available for you.
  • Plan Ahead. If you know you are going to have some big healthcare costs coming up – braces for your son or the new knee for your husband – plan ahead. Consider setting up a Health Savings Account (HSA) offered with some high deductible health plans, or Flexible Spending Account (FSA) to help with the costs.
  • Ask for Help. There are programs designed to help people with extraordinary costs or low income.

Want to Know More?

Health insurance can be a confusing topic. A couple of resources for more information are listed below. But remember: the costs for you and your family will be determined by your healthcare plan. Read your Member Handbook, and call Customer Service with any questions.


Contact Presbyterian’s friendly Customer Service Center
Weekdays, 7:00 a.m. – 6:00 p.m.
TTY: 1-877-298-7407


 The Difference Between Deductibles and Copays


 What Does In-Network and Out-of-Network Mean?


 The Difference Between Prior Authorization and Referrals