A copay (copayment) i a fixed dollar amount you pay for a covered ervice, uch a $30 for a doctor vi it or $10 for a generic pre cription. You u ually pay it at the vi it, and your plan pay the re t of the allowed amount. A copay i different from coin urance, which i a percentage of the bill, like 20%. Your plan' Summary of Benefit and Coverage (SBC) li t the copay for each kind of ervice.

Coin urance i your hare of the co t of a covered ervice, a a percentage of the allowed amount, u ually after you've met your deductible. With 20% coin urance and a $900 allowed amount, you pay $180 and the plan pay $720. "80/20" mean the plan pay 80% and you pay 20%. Coin urance top once you reach your out-of-pocket maximum.

When should I sign up for Medicare, and is there a late penalty?

Your initial enrollment period la t 7 month : the 3 month before the month you turn 65, that month, and the 3 month after. If you mi it without other qualifying coverage, the Part B penalty i 10% for each full 12 month you could have had Part B, for a long a you have it. The Part D penalty i 1% for each month without creditable drug coverage.

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Common health insurance questions

Q: Does my copay count toward my deductible?

U ually not. On mo t plan , copay do not count toward the deductible, but they do count toward your out-of-pocket maximum. Some plan do credit copay to the deductible, o check your plan' Summary of Benefit and Coverage. Deductible payment , copay and coin urance for covered in-network care all add up toward the out-of-pocket maximum. Premium , balance bill and ervice your plan doe n't cover never count.

Q: Do I have to meet my deductible before my copay applies?

It depend on your plan. Some plan let a copay apply right away, before you meet the deductible. Other apply the copay only after the deductible i met; until then you pay the full allowed amount. Your Summary of Benefit and Coverage ay which, ervice by ervice. Copay applie right away. The SBC read omething like "$30 copay/vi it, deductible doe not apply." You pay $30 even if you haven't paid anything toward your deductible. Many employer HMO and PPO plan work thi way for office vi it , urgent care and generic drug . Copay after the deductible. The SBC read "$30 copay after deductible." HealthCare.gov' example: if the allowed amount for a vi it i $100 and your copay i $20, you pay the full $100 until your deductible i met, then $20 a vi it. HSA-qualified high-deductible plan (HDHP ) generally can't pay for care other than preventive care (and ome telehealth) until the deductible i met, o you pay the full allowed amount fir t. Preventive care from an in-network provider i $0 on mo t ACA plan either way. Try both de ign in the claim co t calculator: et "In-network co t- haring" to "Flat copay (deductible waived)" or to "Deductible, then coin urance."

Q: Do copays count toward my out-of-pocket maximum?

Ye , on ACA-compliant plan . Copay , coin urance and deductible payment for covered in-network care all count toward the out-of-pocket maximum. Once you reach it, the plan pay 100% of covered in-network care for the re t of the plan year. Premium , out-of-network care (unle your plan ha a eparate out-of-network limit), balance bill and non-covered ervice don't count.

Q: What's the difference between a copay and coinsurance?

A copay i a flat dollar amount, like $30 a vi it. Coin urance i a percentage of the allowed amount: 20% of a $900 MRI i $180. Coin urance u ually tart after the deductible; a copay may or may not, depending on the plan.

Q: What is a deductible?

The deductible i the amount you pay for covered care each plan year before your plan tart haring the co t. With a $1,500 deductible, you pay the fir t $1,500 of covered, allowed charge , except for ervice your plan cover before the deductible, like preventive care. Deductible re et at the tart of each plan year. On family plan there i u ually an amount per per on and a larger amount for the whole family.

Q: Does my monthly premium count toward my deductible?

No. The premium i the price of having coverage. It never count toward the deductible or the out-of-pocket maximum.

Q: What is an out-of-pocket maximum?

It' the mo t you'll pay in a plan year for covered in-network care. For 2026 Marketplace plan it can't be more than $10,600 for one per on or $21,200 for a family. For 2027 the limit are $12,000 and $24,000. Once your deductible, copay and coin urance reach the limit, the plan pay 100% of covered in-network care until the plan year end .

Q: What is the allowed amount?

The allowed amount i the mo t your plan will pay for a covered ervice, al o called the negotiated rate or eligible expen e. Your deductible, copay and coin urance are all figured from it, not from the provider' full charge.

Last reviewed November 3, 2026 · Educational use only

Short, plain answers to the questions people ask most, each with links to the official sources it is based on. Plans differ, so your plan's Summary of Benefits and Coverage has the final word.

Copays and deductibles

What is a copay?

Short answer: A copay (copayment) is a fixed dollar amount you pay for a covered service, such as $30 for a doctor visit or $10 for a generic prescription. You usually pay it at the visit, and your plan pays the rest of the allowed amount.

A copay is different from coinsurance, which is a percentage of the bill, like 20%. Your plan's Summary of Benefits and Coverage (SBC) lists the copay for each kind of service.

Learn more: Cost-sharing basics

Sources: HealthCare.gov: Copayment · HealthCare.gov: Summary of Benefits and Coverage

Does my copay count toward my deductible?

Short answer: Usually not. On most plans, copays do not count toward the deductible, but they do count toward your out-of-pocket maximum. Some plans do credit copays to the deductible, so check your plan's Summary of Benefits and Coverage.

Deductible payments, copays and coinsurance for covered in-network care all add up toward the out-of-pocket maximum. Premiums, balance bills and services your plan doesn't cover never count.

Learn more: What counts toward what

Sources: HealthCare.gov: Out-of-pocket maximum · HealthCare.gov: Deductible · HealthCare.gov: Summary of Benefits and Coverage

Do I have to meet my deductible before my copay applies?

Short answer: It depends on your plan. Some plans let a copay apply right away, before you meet the deductible. Others apply the copay only after the deductible is met; until then you pay the full allowed amount. Your Summary of Benefits and Coverage says which, service by service.

Copay applies right away. The SBC reads something like "$30 copay/visit, deductible does not apply." You pay $30 even if you haven't paid anything toward your deductible. Many employer HMO and PPO plans work this way for office visits, urgent care and generic drugs.
Copay after the deductible. The SBC reads "$30 copay after deductible." HealthCare.gov's example: if the allowed amount for a visit is $100 and your copay is $20, you pay the full $100 until your deductible is met, then $20 a visit.
HSA-qualified high-deductible plans (HDHPs) generally can't pay for care other than preventive care (and some telehealth) until the deductible is met, so you pay the full allowed amount first.
Preventive care from an in-network provider is $0 on most ACA plans either way.

Try both designs in the claim cost calculator: set "In-network cost-sharing" to "Flat copay (deductible waived)" or to "Deductible, then coinsurance."

Learn more: Claim cost calculator · Cost-sharing basics

Sources: HealthCare.gov: Copayment · HealthCare.gov: Deductible · HealthCare.gov: Summary of Benefits and Coverage · IRS Publication 969

Do copays count toward my out-of-pocket maximum?

Short answer: Yes, on ACA-compliant plans. Copays, coinsurance and deductible payments for covered in-network care all count toward the out-of-pocket maximum. Once you reach it, the plan pays 100% of covered in-network care for the rest of the plan year.

Premiums, out-of-network care (unless your plan has a separate out-of-network limit), balance bills and non-covered services don't count.

Learn more: What counts toward what

Sources: HealthCare.gov: Out-of-pocket maximum

What's the difference between a copay and coinsurance?

Short answer: A copay is a flat dollar amount, like $30 a visit. Coinsurance is a percentage of the allowed amount: 20% of a $900 MRI is $180. Coinsurance usually starts after the deductible; a copay may or may not, depending on the plan.

Learn more: Cost-sharing basics

Sources: HealthCare.gov: Copayment · HealthCare.gov: Coinsurance

What is coinsurance?

Short answer: Coinsurance is your share of the cost of a covered service, as a percentage of the allowed amount, usually after you've met your deductible. With 20% coinsurance and a $900 allowed amount, you pay $180 and the plan pays $720.

"80/20" means the plan pays 80% and you pay 20%. Coinsurance stops once you reach your out-of-pocket maximum.

Learn more: Cost-sharing basics · Claim cost calculator

Sources: HealthCare.gov: Coinsurance · HealthCare.gov: Out-of-pocket maximum

What is a deductible?

Short answer: The deductible is the amount you pay for covered care each plan year before your plan starts sharing the cost. With a $1,500 deductible, you pay the first $1,500 of covered, allowed charges, except for services your plan covers before the deductible, like preventive care.

Deductibles reset at the start of each plan year. On family plans there is usually an amount per person and a larger amount for the whole family.

Learn more: Cost-sharing basics · Individual vs family

Sources: HealthCare.gov: Deductible

Does my monthly premium count toward my deductible?

Short answer: No. The premium is the price of having coverage. It never counts toward the deductible or the out-of-pocket maximum.

Learn more: Cost-sharing basics

Sources: HealthCare.gov: Premium · HealthCare.gov: Out-of-pocket maximum

What is an out-of-pocket maximum?

Short answer: It's the most you'll pay in a plan year for covered in-network care. For 2026 Marketplace plans it can't be more than $10,600 for one person or $21,200 for a family. For 2027 the limits are $12,000 and $24,000.

Once your deductible, copays and coinsurance reach the limit, the plan pays 100% of covered in-network care until the plan year ends.

Learn more: Key federal figures

Sources: HealthCare.gov: Out-of-pocket maximum

Bills and costs

Why did I get a bill if I have insurance?

Short answer: Insurance pays only its share. You can still owe your deductible, copay or coinsurance, plus anything the plan doesn't cover. An out-of-network provider may also bill the difference between its charge and the allowed amount unless the No Surprises Act protects you. Compare the bill with your EOB: what you owe should match the EOB's "you may owe" amount.

Learn more: EOB decoder · When a bill looks wrong

Sources: Texas Department of Insurance: Explanation of benefits · HealthCare.gov: Allowed amount · CMS: No Surprises Act

Why did I get more than one bill for one visit?

Short answer: One visit often involves several providers who bill separately: the hospital or surgery center (a facility fee), the doctor, and often anesthesia, radiology or a lab. Each sends its own claim, and you get an EOB for each. It doesn't mean you were charged twice, but check every bill against its own EOB.

If one of those providers was out of network at an in-network hospital or surgery center, the No Surprises Act usually limits you to in-network cost-sharing.

Learn more: EOB decoder · The No Surprises Act

Sources: Texas Department of Insurance: Explanation of benefits · CMS: No Surprises Act

Should I pay my medical bill before my EOB arrives?

Short answer: It's usually best to wait. Once your insurer processes the claim, the EOB shows what you owe, and the provider's bill should match it. If the office collects a copay or a deposit up front, ask how they handle any overpayment once the claim is processed.

Learn more: EOB decoder

Sources: Texas Department of Insurance: Explanation of benefits

My EOB shows care I never received. What should I do?

Short answer: It could be a billing mistake or medical identity theft. Call the provider listed and your insurer's fraud line, and ask them to correct the records. If someone used your information, report it at IdentityTheft.gov. People with Medicare should check their Medicare Summary Notice the same way.

Learn more: EOB decoder

Sources: FTC: Medical identity theft · IdentityTheft.gov

When does my deductible reset?

Short answer: At the start of each plan year. Marketplace and most individual plans use the calendar year, so the deductible resets January 1. Employer plans can use a different 12-month plan year, so check yours. What you paid toward the deductible usually doesn't carry over.

Learn more: Plan year and accumulators

Sources: HealthCare.gov: Plan year · HealthCare.gov: Deductible

Does out-of-network care count toward my deductible and out-of-pocket maximum?

Short answer: Usually only toward separate out-of-network limits. PPO and POS plans often have their own out-of-network deductible and out-of-pocket maximum, and some have no out-of-network maximum at all. HMO and EPO plans generally don't cover out-of-network care. Balance bills never count. Care protected by the No Surprises Act counts toward your in-network limits.

Learn more: In vs out of network · Compare both in the calculator

Sources: HealthCare.gov: Out-of-pocket maximum · CMS: No Surprises Act

Can I negotiate a medical bill or get a payment plan?

Short answer: Yes, it's worth asking. Check the bill for errors first and ask for an itemized bill. Then ask the provider about a discount, an interest-free payment plan, or financial assistance. Nonprofit hospitals must have a written financial assistance policy and give it to you free. Get any agreement in writing.

Paying with a credit card can add interest and may end your chance at a payment plan or financial assistance, so ask about those first.

Learn more: When a bill looks wrong

Sources: CFPB: What to do if you can't pay a medical bill · CFPB: Financial help for medical bills · IRS: Hospital financial assistance policies

What is a Good Faith Estimate?

Short answer: A written estimate of expected charges that providers must give people who aren't using insurance to pay, whether uninsured or choosing to self-pay. You're entitled to one when you schedule care at least 3 business days ahead or ask for one. If the final bill is $400 or more above the estimate, you can dispute it through a federal process.

Learn more: The No Surprises Act

Sources: CMS: Good faith estimates · CMS: No Surprises Act

Allowed amounts and networks

What is the allowed amount?

Short answer: The allowed amount is the most your plan will pay for a covered service, also called the negotiated rate or eligible expense. Your deductible, copay and coinsurance are all figured from it, not from the provider's full charge.

Learn more: The order of operations · EOB decoder

Sources: HealthCare.gov: Allowed amount

What's the difference between in-network and out-of-network?

Short answer: In-network providers have a contract with your plan: they accept the allowed amount and can only bill you your cost-sharing. Out-of-network providers have no contract, so your cost-sharing is usually higher and they may bill you the difference. HMO and EPO plans usually don't cover out-of-network care except emergencies.

Learn more: In vs out of network · Compare both in the calculator

Sources: HealthCare.gov: Network · HealthCare.gov: Balance billing

Can a doctor bill me for what my insurance didn't pay?

Short answer: An in-network provider can't bill you more than your copay, deductible and coinsurance for covered services. An out-of-network provider can bill you the difference between its charge and the allowed amount, except where the No Surprises Act protects you: emergencies, out-of-network clinicians at in-network hospitals and surgery centers, and air ambulances.

Learn more: The No Surprises Act

Sources: HealthCare.gov: Balance billing · CMS: No Surprises Act

Choosing a plan

What's the difference between bronze, silver, gold and platinum plans?

Short answer: The metal tiers show how you and the plan split costs on average, not the quality of care. Bronze plans pay about 60% of costs, silver about 70%, gold about 80% and platinum about 90%. Lower tiers have lower premiums but higher costs when you get care. Silver is the only tier with extra cost-sharing reductions for lower incomes.

Learn more: Marketplace metal tiers · Plan comparison

Sources: HealthCare.gov: Health plan categories

What is a catastrophic plan, and who can buy one?

Short answer: A low-premium plan with a very high deductible that protects you from worst-case costs. You can buy one if you're under 30 or qualify for a hardship or affordability exemption. For 2026, CMS also opened them to people who can't get premium tax credits because of their income. They cover preventive care and at least 3 primary care visits a year before the deductible.

You can't use a premium tax credit to pay for a catastrophic plan, so compare it with a bronze plan if you qualify for one. From 2026, catastrophic plans are also HSA-eligible.

Learn more: Marketplace metal tiers

Sources: HealthCare.gov: Catastrophic health plans · CMS: Catastrophic plan access for 2026

Can I get help paying my premium (premium tax credit)?

Short answer: If you buy a Marketplace plan and your household income is at least 100% of the federal poverty level, a premium tax credit may lower your monthly premium. The extra federal help available from 2021 through 2025 expired at the end of 2025, so for 2026 the credit again generally stops at 400% of the poverty level. You usually can't get it if you're offered affordable job-based coverage.

The credit is based on your estimated income for the year. If your income turns out higher, you may have to pay some or all of it back at tax time. Congress could still change these rules, so check HealthCare.gov for your numbers.

Learn more: ACA Marketplace plans

Sources: HealthCare.gov: Premium tax credit · HealthCare.gov: Lower your costs

Is there a penalty for not having health insurance?

Short answer: There's no federal penalty; it ended after 2018. A few places have their own requirement with a state tax penalty: California, Massachusetts, New Jersey, Rhode Island and the District of Columbia. Check your state tax agency for current amounts and exemptions.

Learn more: Who stands behind the plan

Sources: HealthCare.gov: Fee for not having coverage · California Franchise Tax Board: Health care mandate · Massachusetts DOR: 2026 individual mandate penalties · KFF: Does the individual mandate still apply?

What's the difference between an HSA, an FSA and an HRA?

Short answer: An HSA is your own account, paired with an HSA-qualified plan; it rolls over every year and stays with you. A health FSA is an employer plan account you fund from your pay, mostly use-it-or-lose-it each year. An HRA is funded only by your employer, which sets its rules. All three pay qualified medical costs tax-free.

Learn more: Tax-advantaged accounts

Sources: HealthCare.gov: Health savings account · HealthCare.gov: Flexible spending account · HealthCare.gov: Health reimbursement account · IRS Publication 969

Why isn't my prescription covered? What is a formulary?

Short answer: Each plan has a formulary, the list of drugs it covers, usually sorted into tiers with different costs. If your drug isn't on it, ask your doctor about a covered alternative or ask the plan for a formulary exception. Some drugs also need prior authorization or step therapy, which means trying a lower-cost drug first.

Learn more: Drug formularies and tiers

Sources: HealthCare.gov: Formulary · HealthCare.gov: Preauthorization · HealthCare.gov: Appealing a health plan decision

Do I need a referral to see a specialist?

Short answer: It depends on your plan. HMOs and most POS plans require a referral from your primary care doctor before you see a specialist, or the plan may not pay. PPOs and most EPOs don't. Check your plan documents or call the number on your card.

Learn more: Plan types

Sources: HealthCare.gov: Referral · HealthCare.gov: Specialist · HealthCare.gov: HMO

Emergency room or urgent care: what will it cost?

Short answer: Go to the emergency room for an emergency. It's covered in or out of network without prior approval, and the No Surprises Act limits you to in-network cost-sharing. For problems that can't wait but aren't emergencies, an in-network urgent care center usually costs much less. Out-of-network urgent care isn't protected the same way.

Learn more: The No Surprises Act

Sources: HealthCare.gov: Emergency services · HealthCare.gov: Urgent care · CMS: No Surprises Act

Can a plan deny me for a pre-existing condition?

Short answer: Not an ACA-compliant plan. Marketplace and job-based plans can't refuse you, charge you more, or refuse to cover essential health benefits because of a pre-existing condition. Grandfathered individual policies are the exception, and coverage that isn't ACA insurance, such as a short-term plan, can still exclude it.

Learn more: Who stands behind the plan

Sources: HealthCare.gov: Pre-existing conditions

What is COBRA, and how much does it cost?

Short answer: COBRA lets you and your family keep your employer's group plan after you lose eligibility, for example by leaving a job. You pay the full premium plus up to a 2% fee, usually for up to 18 months (longer in some cases), and you generally have 60 days to elect it. Losing job-based coverage also opens a 60-day Marketplace special enrollment period, so compare both.

Learn more: COBRA and other options

Sources: HealthCare.gov: COBRA coverage · HealthCare.gov: COBRA

Coverage and plan types

Is preventive care free?

Short answer: On most ACA plans, yes, from an in-network provider: recommended screenings, vaccines and yearly checkups have no copay, coinsurance or deductible. If the visit also treats a problem, that part can be billed.

Learn more: Other rules that change what is paid

Sources: HealthCare.gov: Preventive care benefits

What's the difference between an HMO and a PPO?

Short answer: An HMO covers only in-network care (except emergencies) and usually requires a primary care doctor and referrals; premiums are usually lower. A PPO lets you see any provider without referrals and covers out-of-network care at a higher cost; premiums are usually higher. An EPO is in-network only, usually without referrals.

Learn more: Plan types

Sources: HealthCare.gov: HMO · HealthCare.gov: PPO · HealthCare.gov: EPO

What is a high-deductible plan (HDHP) and an HSA?

Short answer: A high-deductible health plan has a deductible at or above an IRS minimum: $1,700 for one person or $3,400 for a family in 2026. If it qualifies, you can put pre-tax money in a health savings account (HSA) to pay medical costs. The money is yours and rolls over every year.

2026 HSA contribution limits are $4,400 for self-only coverage and $8,750 for family coverage, plus $1,000 if you're 55 or older.

Learn more: Tax-advantaged accounts

Sources: HealthCare.gov: High-deductible health plan · HealthCare.gov: Health savings account · IRS Publication 969

How does a family deductible work?

Short answer: Most family plans have two limits: one per person and one for the family. With an embedded deductible, a person's coinsurance starts once they meet their own amount or the family total is met. With an aggregate deductible, no one's coinsurance starts until the whole family amount is met.

Learn more: Individual vs family · Family deductible simulator

Sources: HealthCare.gov: Deductible · IRS Publication 969

Does medical insurance cover an oral appliance for sleep apnea?

Short answer: Often, yes. A custom oral appliance for obstructive sleep apnea is usually billed to your medical plan, not your dental plan, because it treats a medical condition. That's why your dentist may bill your medical insurance. Plans typically require a sleep study and a physician's diagnosis, and many require prior authorization.

Original Medicare covers a custom appliance when its criteria are met: an in-person evaluation, a qualifying sleep test, an order from the treating practitioner after the test, and a device provided by a licensed dentist. It doesn't require trying CPAP first.

Learn more: Dental practices billing medical plans

Sources: CMS: Oral appliances for obstructive sleep apnea (LCD L33611)

Bills, claims and appeals

Is an Explanation of Benefits (EOB) a bill?

Short answer: No. An EOB is your insurer's statement for a processed claim: what the provider charged, what the plan allowed and paid, and what you may owe. Wait for the provider's bill, then check that it matches the EOB's "you may owe" amount.

Learn more: EOB decoder

Sources: HealthCare.gov: Allowed amount

What is prior authorization?

Short answer: Prior authorization is approval from your plan before certain services, like imaging, surgery or specialty drugs. Without it the plan can deny the claim even when the service is covered. Your provider usually asks for it; check before your appointment.

Learn more: Prior authorization

Sources: HealthCare.gov: Preauthorization

How do I appeal a denied claim?

Short answer: Read the denial reason on your EOB, then file an internal appeal with your plan, usually within 180 days. If the plan upholds the denial, you can ask for an independent external review. Include your records and a letter from your provider.

Learn more: Deadlines and appeals

Sources: HealthCare.gov: Appealing a health plan decision · CMS: Medicare fee-for-service appeals

If I have two health plans, which one pays first?

Short answer: A plan that covers you as an employee pays before one that covers you as a dependent. For children covered by both parents, the birthday rule usually applies: the plan of the parent whose birthday comes first in the calendar year pays first. Medicare has its own order based on employer size.

Learn more: Coordination of benefits

Sources: HealthCare.gov: Coordination of benefits · Medicare.gov: How Medicare works with other insurance

Enrollment and family

How long can my child stay on my health plan?

Short answer: Until age 26, whether or not they're married, in school, living with you, or eligible for their own job-based coverage.

Learn more: Who can be on a family plan

Sources: HealthCare.gov: Coverage for young adults under 26

Short answer: During open enrollment, or in a special enrollment period after a life event such as losing coverage, marriage, birth or adoption, or moving. For 2027 Marketplace coverage, HealthCare.gov open enrollment runs November 1, 2026 to January 15, 2027.

Learn more: Enrollment windows

Sources: HealthCare.gov: Open enrollment period · HealthCare.gov: Special enrollment period · HealthCare.gov: Dates and deadlines

What is a qualifying life event?

Short answer: A change in your life that lets you enroll or change plans outside open enrollment, such as losing other coverage, getting married, having or adopting a child, or moving. For Marketplace plans you generally have 60 days from the event; job-based plans must give you at least 30 days.

Learn more: Enrollment windows

Sources: HealthCare.gov: Qualifying life event · HealthCare.gov: Coverage outside open enrollment

How do I add a newborn to my health plan?

Short answer: Tell your plan quickly. Job-based plans must let you add a newborn within at least 30 days, with coverage back to the date of birth. On the Marketplace you have 60 days, and coverage can start on the birth date. If you miss the window, the baby's hospital and doctor bills may not be covered.

Learn more: Who can be on a family plan

Sources: Department of Labor: Protections for newborns and new parents · HealthCare.gov: Coverage outside open enrollment

Medicare

Medicare Advantage or Medigap: what's the difference?

Short answer: Medicare Advantage (Part C) is a private plan that replaces Original Medicare, usually with a network, prior authorization rules and an out-of-pocket limit; many include drug coverage. Medigap is a supplement you add to Original Medicare to pay its deductibles and coinsurance, and you can see any provider that takes Medicare. You can't use both at once.

Timing matters. Your one-time Medigap open enrollment period lasts 6 months, starting the month you're 65 or older and have Part B. Outside it, insurers in most states can turn you down or charge more because of your health.

Learn more: Medicare

Sources: Medicare.gov: Original Medicare vs Medicare Advantage · Medicare.gov: When can I buy Medigap?

Short answer: Your initial enrollment period lasts 7 months: the 3 months before the month you turn 65, that month, and the 3 months after. If you miss it without other qualifying coverage, the Part B penalty is 10% for each full 12 months you could have had Part B, for as long as you have it. The Part D penalty is 1% for each month without creditable drug coverage.

Learn more: Medicare

Sources: Medicare.gov: When can I sign up for Medicare? · Medicare.gov: Avoid late enrollment penalties

Do I need Medicare at 65 if I still have insurance through work?

Short answer: Not always. If you or your spouse are still working and covered by that job's plan, you can usually delay Part B without a penalty and sign up within 8 months after the job or the coverage ends. COBRA and retiree coverage don't count as coverage from current work. Whether Medicare or the job plan pays first depends on the employer's size.

If you put money in an HSA, plan to stop before your Medicare coverage starts, because you can't contribute once you're enrolled.

Learn more: Medicare and other coverage

Sources: Medicare.gov: Working past 65 · Medicare.gov: How Medicare works with other insurance · IRS Publication 969

For billing staff

What does CO-45 mean on a remittance?

Short answer: CO-45 means the charge exceeds the contracted or allowed amount. CO stands for contractual obligation: the provider writes off the difference and can't bill the patient for it.

Learn more: Denial and remit codes

Sources: X12: Claim adjustment reason codes

What is the timely filing limit?

Short answer: It's the deadline for submitting a claim. Original Medicare allows 12 months from the date of service; commercial plans set limits in the provider contract, often 90 to 180 days. A claim the clearinghouse rejected doesn't count as filed.

Learn more: Timely filing

Sources: CMS Medicare Claims Processing Manual, chapter 1 (PDF)

What's the difference between a claim denial and a rejection?

Short answer: A rejection happens before the claim is accepted: the clearinghouse or payer finds a data error, and the claim never reaches adjudication. Fix and resubmit it, and remember it didn't stop the filing clock. A denial comes after adjudication: the payer processed the claim and didn't pay all or part of it, with CARC and RARC codes explaining why. Correct and resubmit, or appeal.

Learn more: Claim lifecycle · Denial and remit codes

Sources: X12: Claim status codes · X12: Claim adjustment reason codes

How long does an insurer have to pay a clean claim?

Short answer: Original Medicare must pay clean claims within 30 days or owe interest, and doesn't pay electronic claims before day 14 (paper claims day 29). Commercial plans follow state prompt-pay laws, often 30 to 45 days for clean electronic claims, and those laws may not reach self-funded ERISA plans. Medicare Advantage contracts set terms for in-network providers.

Learn more: Deadlines and appeals

Sources: CMS: Checking Medicare claim status (PDF) · CMS Medicare Claims Processing Manual, chapter 1 (PDF)

What do PR-1, PR-2, PR-3 and CO-197 mean?

Short answer: PR means patient responsibility: PR-1 is deductible, PR-2 is coinsurance and PR-3 is copay, all billable to the patient. CO-197 means precertification or authorization was missing; because it's a CO (contractual obligation) adjustment, it's the provider's liability, so don't bill the patient. Ask for retro-authorization or appeal.

Learn more: Denial and remit codes

Sources: X12: Claim adjustment reason codes

When do we need an ABN, and can we bill the patient after a denial?

Short answer: Give an ABN (form CMS-R-131) to an Original Medicare patient before a service you expect Medicare to deny as not reasonable and necessary. With a valid, signed ABN (modifier GA), you can bill the patient if Medicare denies it; without one (modifier GZ), you generally can't. ABNs don't apply to Medicare Advantage, and statutorily excluded services use GY.

Learn more: Medicare: Advance Beneficiary Notice

Sources: CMS: Advance Beneficiary Notice (ABN)

What is a network gap exception or single case agreement?

Short answer: A network gap exception asks the plan to cover an out-of-network provider at in-network cost-sharing because no suitable in-network provider is available. A single case agreement is a one-time contract that sets the rate for one patient's care and usually bars balance billing. Request either before care, with codes, diagnosis and why in-network options don't work, and get the approval in writing.

Learn more: Getting in-network benefits

Sources: HealthCare.gov: Network

Should we bill the dental or the medical plan for oral appliance therapy?

Short answer: For obstructive sleep apnea, bill the patient's medical plan: the appliance treats a medical condition and is billed as DME (for example HCPCS E0486) with ICD-10 diagnosis codes on a CMS-1500. Most dental plans exclude it. Medical and dental plans often don't coordinate, so confirm with both before billing if a dental plan does offer coverage.

For Original Medicare, the device must be provided and billed by a licensed dentist enrolled as a Medicare DME supplier, and the LCD criteria must be documented.

Learn more: Dental practices billing medical plans

Sources: CMS: Oral appliances for obstructive sleep apnea (LCD L33611) · HealthCare.gov: Coordination of benefits

Common health insurance questions

Copays and deductibles

What is a copay?

Does my copay count toward my deductible?

Do I have to meet my deductible before my copay applies?

Do copays count toward my out-of-pocket maximum?

What's the difference between a copay and coinsurance?

What is coinsurance?

What is a deductible?

Does my monthly premium count toward my deductible?

What is an out-of-pocket maximum?

Bills and costs

Why did I get a bill if I have insurance?

Why did I get more than one bill for one visit?

Should I pay my medical bill before my EOB arrives?

My EOB shows care I never received. What should I do?

When does my deductible reset?

Does out-of-network care count toward my deductible and out-of-pocket maximum?

Can I negotiate a medical bill or get a payment plan?

What is a Good Faith Estimate?

Allowed amounts and networks

What is the allowed amount?

What's the difference between in-network and out-of-network?

Can a doctor bill me for what my insurance didn't pay?

Choosing a plan

What's the difference between bronze, silver, gold and platinum plans?

What is a catastrophic plan, and who can buy one?

Can I get help paying my premium (premium tax credit)?

Is there a penalty for not having health insurance?

What's the difference between an HSA, an FSA and an HRA?

Why isn't my prescription covered? What is a formulary?

Do I need a referral to see a specialist?

Emergency room or urgent care: what will it cost?

Can a plan deny me for a pre-existing condition?

What is COBRA, and how much does it cost?

Coverage and plan types

Is preventive care free?

What's the difference between an HMO and a PPO?

What is a high-deductible plan (HDHP) and an HSA?

How does a family deductible work?

Does medical insurance cover an oral appliance for sleep apnea?

Bills, claims and appeals

Is an Explanation of Benefits (EOB) a bill?

What is prior authorization?

How do I appeal a denied claim?

If I have two health plans, which one pays first?

Enrollment and family

How long can my child stay on my health plan?

When can I sign up for or change a health plan?

What is a qualifying life event?

How do I add a newborn to my health plan?

Medicare

Medicare Advantage or Medigap: what's the difference?

When should I sign up for Medicare, and is there a late penalty?

Do I need Medicare at 65 if I still have insurance through work?

For billing staff

What does CO-45 mean on a remittance?

What is the timely filing limit?

What's the difference between a claim denial and a rejection?

How long does an insurer have to pay a clean claim?

What do PR-1, PR-2, PR-3 and CO-197 mean?

When do we need an ABN, and can we bill the patient after a denial?

What is a network gap exception or single case agreement?

Should we bill the dental or the medical plan for oral appliance therapy?