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Understanding your member costs

June 13, 2023
What’s a copay? A deductible? An out-of-pocket maximum? How does my plan work if I have to go to a doctor?
Use this guide for a better idea of how it all works.
Preventive care
  • We cover 100% of the allowed amount for yearly checkups, preventive tests and other things that keep you healthy.1
Copay (copayment)
  • When you see a doctor, you pay a set amount to the doctor for the visit. A copay is a fixed dollar amount you pay when you get a medical service, such as when you go to your doctor.
  • Copays don’t count toward your deductible.
  • You pay a set amount toward certain covered services each year before UniCare begins paying benefits for those services.
  • A medical deductible works just like the deductible for your car insurance: it’s the fixed amount you have to pay before your insurance kicks in.
  • Covered services that the deductible applies to include labs, X-rays and surgeons’ fees.
  • Some health care bills are shared between you and UniCare. This is called coinsurance.
  • UniCare pays either 80% or 100% of the allowed amount, depending on what the service is.
Out-of-pocket (OOP) maximum
  • To protect you from high costs, your plan has an out-of-pocket maximum. This maximum is the most you could pay for copays, deductible and coinsurance in a year.
  • Once you reach your out-of-pocket maximum, we pay 100% of covered services for the rest of the plan year. (Your plan year starts on July 1 and ends on June 30 of the next year.)
  • Your member costs (copays, deductible and coinsurance) count toward reaching your out-of-pocket maximum. Your member handbook lists other costs, such as your insurance premiums, that don’t count.
1- Includes preventive services recommended by the U.S. Preventive Services Task Force. Frequency of preventive exams is based on Massachusetts Health Quality Partners (MHQP) guidelines.