A Basic Explanation

When you visit a doctor, the amount you’ll have to pay will depend on what type of doctor you’re seeing and what the office visit is for. And also on what type of health plan you have.

Some plans charge just a small fee, known as a copay, for doctors’ visits. With others, your insurance company will pay a percentage of the cost once you’ve met your deductible, an arrangement known as coinsurance. Still other types of plans use a combination of copays and coinsurance to share the costs.

Expert Advice About Office Visits

Read through your plan benefits carefully so you understand exactly how your insurer handles trips to the doctor (and what payments are expected of you). Here’s how many plans typically deal with cost-sharing for different types of office visits.

Preventive Services Visit: There is no charge for an office visit when you see your in-network primary care physician (PCP) for a flu vaccine, blood pressure check, an annual physical (for women and children), or any other services considered preventive care under the Affordable Care Act (ACA). You might get a bill if your doctor orders additional tests or performs other services – but covered preventive visits are free.

Primary Care Visit: If, for example, you go to your PCP for a nagging cough, an unusual rash, or any other fairly routine matter about your overall health, some plans charge you a small copay. With others (including most bronze plans), you’ll have to pay the full cost of all visits until you reach your deductible. As always, be sure to check with your insurance company to see how these kinds of office visits are covered.

Specialist Visits: While your primary care doctor performs routine checkups and is generally the overseer of your healthcare, a specialty doctor – or specialist – addresses particular types of illness or specific parts of your body. If, for instance, you come down with a urinary tract infection, you may need to see a urologist. Or if your bad back starts acting up, you may want to see an orthopedic specialist.

Plans with copays often charge a slightly higher fee when you see a specialist; some plans (HMOs and EPOs) require a referral from your primary care doctor before seeing a specialist, even if the specialist is in your network.

With other plans it works the same as for a visit to your primary care doctor: You may have to pay the entire cost of all doctor visits until you reach your deductible before your coinsurance kicks in (and your insurer starts sharing your healthcare costs).

Other Provider Visits: Some plans offer limited coverage for services from other types of specialists who aren’t MDs: chiropractors, physical therapists, registered dietitians, even alternative and complementary practitioners such as acupuncturists. If your plan does include these benefits, make sure you check to see how many visits are allowed and how much the plan will pay.

What else you need to know

Office visit fees may vary among plans, but don’t focus too much on those numbers beyond whether you have to meet your deductible before your insurance kicks in. It’s usually more important to consider the overall costs of your healthcare when comparing and choosing a plan. Then take a look at the metal tiers to better understand the levels of coverage offered under the ACA.