Primary Care Costs Explained

Carbon Health Editorial Team
January 5, 2022
5 mins

At Carbon Health, we believe that an important element of delivering compassionate, convenient care is making our pricing transparent and our billing easy to understand. As your healthcare partner, we’re always here to help you understand medical costs, including what your insurance will and won’t cover — with no surprises and no additional fees. 

In this post, we’re answering some commonly asked questions about our prices and insurance partnerships, to help you make informed decisions about your health.

+ How do co-pays and deductibles work? 

No matter what type of insurance you have, you will likely have to pay some co-pays and deductibles, based on your plan benefits. 

Co-pays A co-pay (short for “co-payment”) is a fixed amount you will be responsible for paying for medical services that your insurer covers. The remaining balance is covered by your insurance company. Co-pays often vary for different services within the same plans. For example, co-pays for standard doctor visits are typically lower than those for visits to specialists.

Deductibles — A deductible is a fixed amount you must pay each year before your health insurance begins to cover the costs. After meeting your deductible amount, you will typically pay a certain percentage of costs, or a co-pay, for services that are covered by the plan. 

In general, plans that charge lower monthly premiums have higher co-pays and higher deductibles, while plans that charge higher monthly premiums have lower co-pays and lower deductibles. Choosing between these two plan types is frequently a matter of considering your typical health needs in a year and then calculating which plan makes the most sense. 

To get your specific co-pay cost amount for a Carbon Health visit, we’ll need to see your insurance card and verify your insurance coverage and benefits. We recommend that you call the member services number on the back of your insurance card and ask about coverage and co-pay amounts. 

+ What is an out-of-pocket cost?

An out-of-pocket cost is the amount of money you are required to pay for healthcare services. 

There are three primary reasons you would have to pay money out-of-pocket. 

When you haven’t yet met your deductible — You will typically pay out-of-pocket costs for services until you meet your insurance plan’s deductible.

When you need services your insurance plan doesn’t cover — Some procedures may not be covered by your insurance plan (or may be covered only a certain number of times — for example, one Pap smear per calendar year); when this is the case, you will be responsible for the full cost.

When you don’t have insurance — If you don’t have insurance coverage, costs are your responsibility and are considered out-of-pocket. However, there are certain financial assistance programs that may be available to you, to help you pay for healthcare expenses. The Affordable Care Act provides consumers with subsidies (premium tax credits) that lower the cost of healthcare for households with incomes between 100 percent and 400 percent of the U.S. Federal Poverty Guidelines

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+ What’s the difference between an HMO and a PPO? 

Two of the most common types of managed care plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs), which are intended to help insurers lower costs while improving the quality of care that patients receive.

HMO — With an HMO plan, you always have to see your primary care provider first when you’re experiencing a health issue. If your provider is unable to treat the problem, they will refer you to an in-network specialist. Under an HMO plan, you must stay within your network of providers to receive insurance coverage. 

PPO — With a PPO plan, you can schedule an appointment with a specialist without a referral. You still have a designated network of providers, but you aren’t restricted to seeing only those providers. Instead, you may visit any healthcare provider you wish, with the understanding that there may be additional costs. 

Typically, if you stay within your network with an HMO, you can expect your insurance company to provide the maximum coverage according to your benefit plan. However, if you go outside of your network, they provide no coverage. With a PPO, you can visit doctors outside of your network and still get some coverage, with higher out-of-pocket costs than if you remained within your preferred network.

+ Which insurance carriers does Carbon Health accept?

Carbon Health has contracts with most insurance carriers, covering PPO, HMO, and Medicare Advantage plans. However, the answer to this question will differ by state. You can find a complete list of accepted insurance carriers on our website’s Insurance & Pricing page.

If you don't see your insurance carrier listed, please give your insurance provider a call to double-check. The number can be found on your plan card. Service and benefit coverage vary based on geographic location and may differ depending on whether you are seeking an urgent care or primary care visit. While Carbon Health does accept Medicare, at this time we do not accept Medicaid.

At Carbon Health, we know that cost transparency is important to our patients — and we’re here to help in any way we can. Our providers and our clinic staff are ready to listen and help you navigate your health costs. Book an appointment for an in-person or virtual visit today.

Carbon Health Editorial Team

The Carbon Health Editorial Team is a group of writers, content creators, and thought leaders who are here to empower you to take charge of your health.