Ppo Copay
These examples show how HMSA calculates your copayment for covered services if your HMSA plan pays 90% of the eligible charge when you see a participating provider and 70% when you see a nonparticipating provider. Copayment%ages may differ. Refer to your Guide to Benefits for your specific copayment%ages.
Specialist has higher copay. Certain services may require Preauthorization. Inpatient services 10% coinsurance $100 copay/day then 20% coinsurance 40% coinsurance Preauthorization is required. Max copay $500 per admission. If you are pregnant Office visits $20/$25 copay initial visit then 10% coinsurance $30/$35 copay initial visit then. Home / Help Center / Calculating Your PPO Plan Copayment. Print Share Calculating Your PPO Plan Copayment. Last Modified: 2/23/2012 10:13:04 AM. Article: KB00046. $0 copay $40 copay $0 copay Specialist $35 copay 40% of the cost $0 copay Preventive Care With Medicare only In. Humana is a Medicare Advantage PPO plan with a Medicare contract. Enrollment in this Humana plan depends on contract renewal. Acute inpatient hospital care $300 copay per day for days 1-5 $0 copay per day for days 6-90 40% of the cost $0 deductible $0 copay per day for days 1-60 $0 copay per day for days 61-90 $0 copay per day for days 91-150 Lab Services With Medicare only In - Networkre only In - Network With Medicare only Out-of-Network. A PPO health insurance plan provides more choices when it comes to your healthcare, but there will also be higher out-of-pocket costs associated with these plans. Your monthly premiums will be higher and your copays for office visits will also cost more.
Physician visit
When your copayment is 10% of the eligible charge for services from a participating physician and 30% for services from a nonparticipating physician:
You have a cold and go to a participating physician to have it checked out.
- The physician’s bill or actual charge is $100.
- HMSA’s eligible charge is $80.
- Your copayment is $8 (10% of $80).
If you went to a nonparticipating physician, you’d owe a copayment of 30% of the eligible charge plus the difference between the eligible charge and the physician’s actual charge. The nonparticipating physician may require payment of the actual charge at the time of service.
- The physician’s bill or actual charge is $100.
- HMSA’s eligible charge is $80.
- HMSA will reimburse you $56 (70% of $80).
- Your total out-of-pocket cost is $44.
| Physician | Physician’s Actual Charge | Eligible Charge | Your Copayment | Calculation to Determine Your Portion of the Costs | Your Portion |
|---|---|---|---|---|---|
| Participating | $100 | $80 | 10% of eligible charge | $80 x 10% = $8 | $8 |
| Nonparticipating | $100 | $80 | 30% of eligible charge | $80 x 30% = $24 Difference between eligible charge and actual charge = $20 $24 + $20 = $44 | $44* |
*Note: Because services were provided by a nonparticipating physician, your physician may require payment of the actual charge of $100 and you may need to file your own claim.
Surgical procedure — physician charge
When your copayment is 10% of the eligible charge for services from a participating physician and 30% for services from a nonparticipating physician:
You have a major surgical procedure done by a participating physician.
- The physician’s bill or actual charge is $100,000.
- HMSA’s eligible charge is $40,000.
- Your copayment is $4,000 (10% of $40,000).
If you went to a nonparticipating provider, you’d owe a copayment of 30% of the eligible charge plus the difference between the eligible charge and the physician’s actual charge. The nonparticipating physician may require payment of the actual charge at the time of service.
- The physician’s bill or actual charge is $100,000.
- HMSA’s eligible charge is $40,000.
- HMSA will reimburse you $28,000 (70% of $40,000).
- Your total out-of-pocket cost is $72,000.
| Physician | Physician’s Actual Charge | Eligible Charge | Your Copayment | Calculation to Determine Your Portion of the Costs | Your Portion |
|---|---|---|---|---|---|
| Participating | $100,000 | $40,000 | 10% of eligible charge | $40,000 x 10% = $4,000 | $4,000 |
| Nonparticipating | $100,000 | $40,000 | 30% of eligible charge | $40,000 x 30% = $12,000 Difference between eligible charge and actual charge = $60,000 $12,000 + $60,000 = $72,000 | $72,000* |
*Note: Because services were provided by a nonparticipating physician, your physician may require payment of the actual charge of $100,000 and you may need to file your own claim.
With so many benefits, it’s important to understand your Advantage MD coverage to get the most out of your health care. Use the chart below to see your benefits at-a-glance.
For specific information on your benefits, use our interactive tool to browse your covered benefits. You can also download a PDF of your plan’s summary of benefits.
- Summary of Benefits – English | Spanish
Switch between Advantage MD Plans* and Original Medicare
| Advantage MD Plans | ||||
|---|---|---|---|---|
| Plans & Monthly Plan Premium | ||||
| Plans & Monthly Plan Premium | Johns Hopkins | Johns Hopkins | Johns Hopkins | Johns Hopkins |
| MEDICAL BENEFITS (partial listing: in-network) | ||||
| MEDICAL BENEFITS (partial listing: in-network) | ||||
| Medical Deductible | ||||
| Medical Deductible | $0 | $0 | $0 | $0 |
| Primary Care Provider Visit | ||||
| Primary Care Provider Visit | $5 copay | $10 copay | $5 copay | $0 copay |
| Specialist Visit | ||||
| Specialist Visit | $50 copay | $50 copay | $50 copay | $10 copay |
| Referrals | ||||
| Referrals | Required for Specialist Visits only | Not required | Not required | Not required |
| Urgent Care | ||||
| Urgent Care | $40 copay The copay is not waived if you are admitted to the hospital. | $40 copay. The copay is not waived if you are admitted to the hospital. | $40 copay The copay is not waived if you are admitted to the hospital. | $20 copay The copay is not waived if you are admitted to the hospital. |
| Telemedicine | ||||
| Telemedicine | $5 copay for PCP visits $50 copay for specialists and other office visits $40 copay for urgent care visits | $10 copay for PCP visits $50 copay for specialists and other office visits $40 copay for urgent care visits | $5 copay for PCP visits $50 copay for specialists and other office visits $40 copay for urgent care visits | $0 copay for PCP visits $10 copay for specialists and other office visits $20 copay for urgent care visits |
| Ambulatory Surgical Centers Outpatient Surgery | ||||
| Ambulatory Surgical Centers Outpatient Surgery | $225 copay | $225 copay | $225 copay | $50 copay |
| Emergency Care | ||||
| Emergency Care | $90 copay The copay is waived if you are admitted to the hospital within 24 hours for the same condition. | $90 copay The copay is waived if you are admitted to the hospital within 24 hours for the same condition. | $90 copay The copay is waived if you are admitted to the hospital within 24 hours for the same condition. | $90 copay The copay is waived if you are admitted to the hospital within 24 hours for the same condition. |
| Worldwide Emergency & Urgently Needed Services | ||||
| Worldwide Emergency & Urgently Needed Services | Not covered | Not covered | $90 copayment for Emergency Care and $40 copayment for Urgently Needed Services | $90 copayment for Emergency Care and $20 copayment for Urgently Needed Services |
| Inpatient Hospital Stay | ||||
| Inpatient Hospital Stay | $310/day copay for days 1-5; $0 copay for days 6-90; Medicare allows 60 'lifetime reserve' days | $310/day copay for days 1-6; $0 copay for days 7-90; Medicare allows 60 'lifetime reserve' days | $310/day copay for days 1-6; $0 copay for days 7-90; Medicare allows 60 'lifetime reserve' days | $200 copay per admission (90 days); Medicare allows 60 'lifetime reserve' days |
| Vision benefits | ||||
| Vision benefits | $50 copay once per year; up to $150 allowance for additional eyewear every two years | $0 copay once per year; no additional eyewear coverage | $0 copay once per year; up to $150 allowance for additional eyewear every two years | $0 copay once per year; up to $300 allowance for additional eyewear every two years |
| Routine Podiatry Services | ||||
| Routine Podiatry Services | 20% coinsurance (up to 8 times per year) | 20% coinsurance (up to 6 times per year) | 20% coinsurance (up to 6 times per year) | $10 copay (up to 12 times per year) |
| Acupuncture | ||||
| Acupuncture | 20% coinsurance (up to 12 visits within 90 days) for chronic lower back pain | 20% coinsurance (up to 12 visits within 90 days) for chronic lower back pain | 20% coinsurance (up to 12 visits within 90 days) for chronic lower back pain. $200 supplemental benefit for any injury or illness. | 20% coinsurance (up to 12 visits within 90 days) for chronic lower back pain. $300 supplemental benefit for any injury or illness. |
| Preventive Dental Services | ||||
| Preventive Dental Services | $15 copay (cleaning); $15 copay (oral exam); $25 copay (dental x-ray) Frequency depends on type of service | $15 copay (cleaning); $15 copay (oral exam); $25 copay (dental x-ray) Frequency depends on type of service | $10 copay (cleaning); $10 copay (oral exam); $20 copay (dental x-ray) Frequency depends on type of service | $0 copay (cleaning); $0 copay (oral exam); $0 copay (dental x-ray); $0 copay (Fluoride treatment) Frequency depends on type of service |
| Optional Supplemental Benefits Learn More | ||||
| Optional Supplemental Benefits Learn More | Available for an extra premium ($30) for comprehensive dental and fitness. | Available for an extra premium ($30) for comprehensive dental and fitness. | Available for an extra premium ($28) for comprehensive dental. | Comprehensive dental and fitness benefits included at no additional cost. |
| Routine Chiropractic Services | ||||
| Routine Chiropractic Services | Not covered | Not covered | $20 copay (up to 12 times per year) | $10 copay (up to 12 times per year) |
| Hearing Aid Services Learn More | ||||
| Hearing Aid Services Learn More | Two options available through TruHearing (up to two per year); copay from $699 per aid | Two options available through TruHearing (up to two per year); copay from $699 per aid | Two options available through TruHearing (up to two per year); copay from $699 per aid | Two options available through TruHearing (up to two per year); copay from $399 per aid |
| Silver&Fit® Program Learn More | ||||
| Silver&Fit® Program Learn More | Included in optional supplemental benefits for an additional premium | Included in optional supplemental benefits for an additional premium | Included | Included |
| PRESCRIPTION DRUG BENEFITS (30-day supply; in-network pharmacy) | ||||
| PRESCRIPTION DRUG BENEFITS (30-day supply; in-network pharmacy) | ||||
| Deductible | ||||
| Deductible | $0 | $350 deductible (applicable to tiers 3, 4, and 5) | $350 deductible (applicable to tiers 3, 4, and 5) | $0 |
| Preferred Generic | ||||
| Preferred Generic | $0 copay | $7 copay | $4 copay | $3 copay |
| Generic | ||||
| Generic | $10 copay | $15 copay | $12 copay | $10 copay |
| Preferred Brand | ||||
| Preferred Brand | $47 copay | $47 copay | $47 copay | $40 copay |
| Non-Preferred Drug | ||||
| Non-Preferred Drug | $100 copay | $100 copay | $100 copay | $90 copay |
| Specialty Tier | ||||
| Specialty Tier | 33% of the cost | 26% of the cost | 26% of the cost | 33% of the cost |
| Mail Order | ||||
| Mail Order | Available | Available | Available | Available |
| Comprehensive Dental Benefits | ||||
|---|---|---|---|---|
| BASIC RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| BASIC RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| Endodontics | ||||
| Endodontics | $200 copay | $200 copay | $200 copay | 50% coinsurance |
| Oral Surgery | ||||
| Oral Surgery | $50 copay | $50 copay | $50 copay | 20% coinsurance |
| Oral Pathology Biopsy | ||||
| Oral Pathology Biopsy | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Periodontics | ||||
| Periodontics | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Restorative Fillings | ||||
| Restorative Fillings | $50 copay | $50 copay | $50 copay | 20% coinsurance |
| General Anesthesia (when medically necessary and administered in connection with oral or dental surgery) | ||||
| General Anesthesia (when medically necessary and administered in connection with oral or dental surgery) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| MAJOR RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| MAJOR RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| Bridges Installation or Addition (due to the covered extraction of one or more natural teeth) | ||||
| Bridges Installation or Addition (due to the covered extraction of one or more natural teeth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Bridges Adjustment or Repair (due to the covered extraction of one or more natural teeth) | ||||
| Bridges Adjustment or Repair (due to the covered extraction of one or more natural teeth) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Bridges Replacement (due to structural changes in the mouth) | ||||
| Bridges Replacement (due to structural changes in the mouth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Installation | ||||
| Crowns, Inlays and Onlays Installation | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Adjustment or Repair (more than six months after installation) | ||||
| Crowns, Inlays and Onlays Adjustment or Repair (more than six months after installation) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Replacement | ||||
| Crowns, Inlays and Onlays Replacement | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Dentures (full or partial) Installation or Addition (due to the covered extraction of one or more natural teeth) | ||||
| Dentures (full or partial) Installation or Addition (due to the covered extraction of one or more natural teeth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Dentures (full or partial) Adjustment or Repair (more than six months after installation) | ||||
| Dentures (full or partial) Adjustment or Repair (more than six months after installation) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Dentures (full or partial) Replacement of Full Denture (due to structural changes in the mouth) | ||||
| Dentures (full or partial) Replacement of Full Denture (due to structural changes in the mouth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
*Please note: this information does not apply to Advantage MD Group.
Johns Hopkins Advantage MD (PPO) has an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD Plus (PPO) has an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD Premier (PPO) has an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD (HMO) has an in-network out-of-pocket maximum of $7,550.
For out-of-network benefits, you pay a percentage for most covered services.
Limitations: 1. Members are responsible for the difference between the allowed amount and the billed amount. For more information, please review the Evidence of Coverage. 2. The comprehensive dental benefit for the Optional Supplement benefits for the Johns Hopkins Advantage MD (HMO) plan, Johns Hopkins Advantage MD (PPO) plan, and Johns Hopkins Advantage MD Plus (PPO) plan has a $1,200 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD Premier (PPO) plan has a $1,500 Annual Maximum.
Prior authorizations are required for the following: endodontics, general anesthesia when medically necessary and administered in connection with oral or dental surgery, oral surgery, periodontics, bridges, crowns, inlays, onlays, and dentures (full or partial).
| 2020 Optional Supplemental Benefits | ||||
|---|---|---|---|---|
| Plans & Additional Monthly Plan Premium | ||||
| Plans & Additional Monthly Plan Premium | Johns Hopkins | Johns Hopkins | Johns Hopkins | Johns Hopkins |
| Fitness Benefit | ||||
| Silver&Fit® Exercise and Healthy Aging Program | ||||
| Silver&Fit® Exercise and Healthy Aging Program | With the Silver&Fit program, you can either choose a fitness center or the Silver&Fit Home Fitness Program. Learn More | With the Silver&Fit program, you can either choose a fitness center or the Silver&Fit Home Fitness Program. Learn More | Included in PPO Plus Plan for no addition premium | Included in PPO Premier Plan for no addition premium |
| Comprehensive Dental Benefits | ||||
|---|---|---|---|---|
| BASIC RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| BASIC RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| Endodontics | ||||
| Endodontics | $200 copay | $200 copay | $200 copay | 50% coinsurance |
| Oral Surgery | ||||
| Oral Surgery | $50 copay | $50 copay | $50 copay | 20% coinsurance |
| Oral Pathology Biopsy | ||||
| Oral Pathology Biopsy | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Periodontics | ||||
| Periodontics | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Restorative Fillings | ||||
| Restorative Fillings | $50 copay | $50 copay | $50 copay | 20% coinsurance |
| General Anesthesia (when medically necessary and administered in connection with oral or dental surgery) | ||||
| General Anesthesia (when medically necessary and administered in connection with oral or dental surgery) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| MAJOR RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| MAJOR RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| Bridges Installation or Addition (due to the covered extraction of one or more natural teeth) | ||||
| Bridges Installation or Addition (due to the covered extraction of one or more natural teeth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Bridges Adjustment or Repair (due to the covered extraction of one or more natural teeth) | ||||
| Bridges Adjustment or Repair (due to the covered extraction of one or more natural teeth) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Bridges Replacement (due to structural changes in the mouth) | ||||
| Bridges Replacement (due to structural changes in the mouth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Installation | ||||
| Crowns, Inlays and Onlays Installation | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Adjustment or Repair (more than six months after installation) | ||||
| Crowns, Inlays and Onlays Adjustment or Repair (more than six months after installation) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Replacement | ||||
| Crowns, Inlays and Onlays Replacement | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Dentures (full or partial) Installation or Addition (due to the covered extraction of one or more natural teeth) | ||||
| Dentures (full or partial) Installation or Addition (due to the covered extraction of one or more natural teeth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Dentures (full or partial) Adjustment or Repair (more than six months after installation) | ||||
| Dentures (full or partial) Adjustment or Repair (more than six months after installation) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Dentures (full or partial) Replacement of Full Denture (due to structural changes in the mouth) | ||||
| Dentures (full or partial) Replacement of Full Denture (due to structural changes in the mouth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
Ppo Copay Vs Hdhp
*Please note: this information does not apply to Advantage MD Group.
Limitations: 1. Members are responsible for the difference between the allowed amount and the billed amount. For more information, please review the Evidence of Coverage. 2. The comprehensive dental benefit for the Optional Supplement benefits for the Johns Hopkins Advantage MD (HMO) plan, Johns Hopkins Advantage MD (PPO) plan, and Johns Hopkins Advantage MD Plus (PPO) plan has a $1,200 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD Premier (PPO) plan has a $1,500 Annual Maximum.
Prior authorizations are required for the following: endodontics, general anesthesia when medically necessary and administered in connection with oral or dental surgery, oral surgery, periodontics, bridges, crowns, inlays, onlays, and dentures (full or partial).
View our 2019 optional supplemental benefits brochure.
| 2020 Original Medicare Plan | |
|---|---|
| Plans & Monthly Plan Premium | |
| Plans & Monthly Plan Premium | ORIGINAL MEDICARE |
| MEDICAL BENEFITS (partial listing: in-network) | |
| MEDICAL BENEFITS (partial listing: in-network) | |
| Medical Deductible | |
| Medical Deductible | Primary Care Provider Visit |
| Primary Care Provider Visit | Specialist Visit |
| Specialist Visit | Referrals |
| Referrals | Urgent Care |
| Urgent Care | Outpatient Surgery, ASC |
| Outpatient Surgery, ASC | Emergency Care |
| Emergency Care | Inpatient Hospital Stay |
| Inpatient Hospital Stay | Annual Routine Vision Exam |
| Annual Routine Vision Exam | Diagnostic Dental Services Learn More |
| Diagnostic Dental Services Learn More | Supplemental Dental |
| Supplemental Dental | Chiropractic Care |
| Chiropractic Care | Hearing Aid Services |
| Hearing Aid Services | Silver&Fit® Program |
| Silver&Fit® Program | PRESCRIPTION DRUG BENEFITS (30-day supply; in-network pharmacy) |
| PRESCRIPTION DRUG BENEFITS (30-day supply; in-network pharmacy) | |
| Deductible | |
| Deductible | Preferred Generic |
| Preferred Generic | Generic |
| Generic | Preferred Brand |
| Preferred Brand | Non-Preferred Drug |
| Non-Preferred Drug | Specialty Tier |
| Specialty Tier | Mail Order |
| Mail Order | Ppo Copay Plan Ascension Get care anytime, anywhere with Johns Hopkins OnDemand Virtual Care. Connect through your mobile device or computer for a video visit with a health care provider 24/7, from anywhere in the United States. Johns Hopkins OnDemand Virtual Care has providers ready to care for you at any time, no appointment needed. A health care provider is available within minutes to review symptoms and prescribe medications, as necessary. Common uses for this service include minor care concerns, such as:
This service is available to all Advantage MD plan members. Get connected with a provider now or learn more. Do not use Johns Hopkins OnDemand Virtual Care for emergency medical matters. Collapse Johns Hopkins Advantage MD covers up to two hearing aids per year when purchased through TruHearing. Features for 2021Ppo Payment Structure
Coverage includes*
How to Get Hearing Aids
*Three follow-up visits must be used within one year after the date of initial purchase. Forty-five-day trial and hearing aid returns, repairs, and replacements subject to provider and manufacturer fees. For questions regarding fees, contact TruHearing customer service at 1-800-334-1807 (TTY: 711). The Silver&Fit® Exercise and Healthy Aging Program Expand The Silver&Fit® program is designed for older adults and is provided at no additional cost for members who choose the Advantage MD Plus plan. With this program, you have access to the following enrollment options:
You also have access to the following Silver&Fit® program features:
*Services that require an additional cost are not included. Learn more and see what fitness facilities participate by going to www.silverandfit.com. The Silver&Fit® program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit®, Silver&Fit Connected!™ and The Silver Slate® are trademarks of ASH and used with permission herein. All programs and services are not available in all areas. Kits are subject to change. Participating facilities and fitness chains may vary by location and are subject to change. |