Texas General Lines — Life, Accident, Health and HMOHMOsEasy
A Texas HMO member has been referred to an in-network specialist for a non-emergency condition. The HMO's Evidence of Coverage specifies a $30 copayment for specialist visits. If the actual cost of the specialist visit is $200, what is the maximum amount the HMO member is expected to pay for this visit, assuming no deductible applies?
- A$200
- B$170
- C$30
- D$0
Show answer & explanationAnswer & explanation
Correct answer: C. $30
In an HMO, after a referral, the member typically only pays the specified copayment for in-network services. The HMO covers the remaining balance for the contracted rate.
Why the other options are wrong
- A. This would imply the member pays the full cost, which is not the case with an HMO for covered services.
- B. This would be the amount if the member paid the difference between the total cost and a small portion, which is not how HMO copayments work.
- D. Members are usually responsible for their copayment or coinsurance.
HMO Copayment
A copayment is a fixed amount a Health Maintenance Organization (HMO) member pays for a covered healthcare service, typically at the time of service, after which the HMO covers the remaining cost.
- Fixed amount paid by member.
- Paid at time of service.
- HMO covers the rest of the contracted rate.
- Applies to in-network services.
Memory trick: Your small 'co-pay' is all you pay for the doctor's day.