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pay (someone) a visit

Definition of pay (someone) a visit

Examples of pay (someone) a visit in a sentence.

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Dictionary Entries Near pay (someone) a visit

pay (someone) a compliment

pay someone no mind

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“Pay (someone) a visit.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/pay%20%28someone%29%20a%20visit. Accessed 27 Apr. 2024.

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How do copays, coinsurance and deductibles work?

Medically reviewed by Leigh Ann Anderson, PharmD . Last updated on April 23, 2024.

Official answer

Copays, coinsurance and deductibles are terms that apply to the cost-sharing that many Americans pay as part of their medical insurance plans. These dollar amounts have a wide range but may go up to thousands of dollars per year based on your specific health plan.

Jump to the Health Care Insurance Glossary below for a quick explanation of relevant terms.

What is a copay?

A copay (copayment) is a set amount that you pay for a service or product, such as a doctor visit or a medication. You will usually pay this at the time of your visit, or you might be billed for it. You may need to meet your annual deductible before you start paying copays.

Copays are usually determined by your health insurance. You may have a different copay for various services, such as medications, lab tests, and visits to primary care doctors, specialists, urgent care centers or the emergency room.

• For example, you might pay a $20 copay each time you see the doctor for a sick visit. However, for preventive healthcare check-ups and preventive medicines like vaccines you should not have to make a copayment.
• For a prescription, your copay for “preferred”, “Tier 1”, or generic medications may be low, for example $10 or $20, and increase for non-preferred drugs that may be brand name drugs or medicines not on the health plan drug formulary. You pay this amount each time you get a prescription refill. Generics typically have lower copays than brand name drugs.
• In some cases, you may be responsible for the full cost of your medicine until you meet your deductible.
• You will typically pay copays for each visit or refill, or until you reach your annual out-of-pocket maximum set by your health plan (which could be in the thousands of dollars).

Your insurance plan will have a list of copays for you to review for various medicines, doctor visits and medical services. Contact them to determine your insurance deductible, copay, coinsurance or out-of-pocket maximum.

Related : Generic Drug FAQs

What is a deductible? Copay vs. deductible

A deductible is the dollar amount you pay for health care services before your insurance plan starts to pay.

• For example, you may have a $2,000 deductible per year before your insurance plan will pay for certain medical services or medications.
• After you have met the amount of your deductible by paying out of your own pocket, and your insurance plan has a record of this amount, you will then pay either a set copay or a coinsurance (for example: 20%) for services or products.
• In most cases your copay will not go toward your deductible amount.

How do I know if I have met my deductible?

If possible, set up an online portal with your health insurance plan to be sure these expenses are accounted for.

• When items are billed through your insurance card (even if you are still paying your deductible), your health plan will document these items so you can see how close you are to meeting your deductible.
• It is important you make sure that your insurance company is aware of any covered out-of-pocket expenses you have paid for yourself so that this amount can be applied to your deductible.
• Keep all of your receipts for anything you pay for out of your pocket, especially if you paid for something without your insurance card.
• Bottom line: even if you are paying out of pocket for something, you should still have the medical facility submit the charges through your insurance card so they can be applied to your deductible.

Some plans have separate deductibles for certain services, like prescription drugs. Family plans may have both an individual deductible and a family deductible which applies to all family members.

Your deductible amount is typically reset back to the maximum dollar amount once per year on your plan renewal date (which is often Jan 1). You will have to pay your deductible each year before payments are made by your health plan.

Can you have both a copay and deductible? Yes, your plan may include both, for example - having a copay for medical outpatient services like a doctor visit and a deductible for other services like x-ray imaging or CT scans.

Most health plans pay the full cost of certain preventive benefits, like vaccines, mammograms or yearly annuals with $0 copays even before you meet your deductible. Check your health plan details for benefit descriptions.

What is a high deductible plan?

Certain plans, known as “high deductible plans” are less expensive than other plans but have a higher deductible (for example, $4,000 per year).

One advantage to these plans, besides having a lower premium, is you may be able to set up a pre-tax Health Savings Account (HSA) through your employer. You can use the HSA to help pay for your expenses now or in the future. Some employers may contribute extra dollars to your HSA, too, as a benefit.

What happens if you don't meet your deductible?

At the end of your plan year, if you still have a deductible to pay you will not owe it. However, when your new yearly plan starts, you will start over with your full deductible amount.

• For example, if your deductible is $4,000 and you have only paid $2,500 out of pocket towards your annual amount, your $4,000 deductible will begin again on the day your annual plan restarts.
• This can be especially difficult if you have a large amount of medical expenses towards the end of your plan year. You may get close to paying off your deductible, but then when the annual plan restarts, you will be responsible for paying yet another full annual deductible before the insurance will pick up any costs.

What happens if I pay more than my deductible?

If for some reason you pay more than your annual deductible, your insurance company will reimburse you for the overpayment. Contact your insurance plan and explain your situation so that they can document it, and investigate for a refund.

To avoid this scenario, be sure to review your Explanation of Benefits (EOB) sent to you by the insurance company and match it up with any medical bills you may have.

Is it better to have a low or high deductible?

In general, health plans that cost less (with lower premiums) have higher deductibles, and plans that are more costly have lower deductibles. Which plan is best for you will depend upon your circumstances, such as age, health and ability to pay for your premiums.

To determine your specific costs, call your the customer service phone number listed on the back of your insurance card, or look at your plan online.

What is coinsurance? Is coinsurance the same as a copay?

No, coinsurance is not the same as a copay. Coinsurance is the percentage of costs that you pay after you have met your deductible (such as a 20% coinsurance). For example, if a doctor’s visit cost $100, you will pay 20% (or $20) once you have met your full deductible. If you still have not met your deductible, you pay the full amount of the doctor’s visit, or $100.

As another example, say these are your yearly plan benefit fees:

• $3,000 deductible
• 20% coinsurance
• $8,000 out-of-pocket maximum

Let’s say you have surgery and a hospital stay and the allowable fee charged to you is $10,000. If your deductible is $3,000 (and you have not met it), you will pay the first $3,000 out of pocket. If your coinsurance is 20%, you will also pay 20% of the remaining amount ($7,000) which equals $1,400 (your coinsurance). You are responsible for $4,400 and your insurance will pay $5,600.

In math terms: $10,000 (charge) - $3,000 (deductible) = $7,000 (x20%) = $1,400 (coinsurance).

You have an out-of-pocket maximum of $8,000. This means you’ll only pay up to that amount per year, and after that your insurance pays 100% of all covered services for the rest of the plan’s calendar year.

What are preventive benefits?

Most health plans must cover certain preventive services at no cost to you. These may include annual well exams, vaccines and cancer screening tests such as a mammogram or colonoscopy. These services will be paid for even if you have not met your deductible, and you typically would not have a copay or coinsurance, either.

There are many other preventive services offered. Your health plan can give you a full outline of these services and how often you can receive them. Preventive services are offered to both adults and children.

Examples of preventive services included in health plans include:

• Blood pressure screening
• Cholesterol screening
• Cancer screenings, for example, mammograms, colonoscopies or cervical cancer
• Immunizations
• Depression or other mental health screenings
• HIV screening; PrEP medication
• Tobacco use screening
• Type 2 diabetes screening
• Obesity screening
• Well-baby and well-child visits
• Birth control (in most cases)

This is not a complete list, so be sure to contact your health plan for a full description of preventive services. These services are also subject to changes as determined by the health plan or government.

What is an Explanation of Benefit?

You may have received an Explanation of Benefit (or "EOB") in the mail or online from your insurance company. What is an EOB? An EOB will tell you how much your insurance paid for a particular covered medical service or product, and what your shared costs are, if any. You should receive one of these forms (in your insurance portal or in the mail) each time a healthcare provider submits a bill to be paid through your insurance.

Be sure that the amount of money you owe on your EOB matches the bill your doctor or medical facility sends to you. If not, call the insurance company or medical billing office to investigate the difference. Mistakes can be made, so take the time to review these EOB documents carefully.

Health Care Insurance Glossary

Copay - A copay is a set dollar amount that you pay for a medical service or product, such as a doctor visit or a medication. You will usually pay this at the time of your visit. For example, your copay each time you see the doctor for a sick visit may be $20. Prescription copays may be $10 for generics or $60 for non-preferred brands.

Coinsurance - Coinsurance is a percentage (%) of a medical charge that you are responsible for paying. For example, if you have a 20% coinsurance and have met your deductible, you will pay 20% of that charge. If a doctor’s visit costs $150, you will pay $30 (20% of $150) as your coinsurance.

Deductible - A deductible is an amount you are required to pay before your insurance will pay towards your expenses. For example, some plans have a $2,000 per year deductible. Once you meet this amount, your insurance will then pay for covered services, minus any copays or coinsurance you may be responsible for.

Explanation of Benefit (EOB) - A mailed or online document that explains what was paid to the medical provider for a service or product, based on your plan coverages. If you owe the provider anything, it will be outlined in this document. Your bill from the doctor and your Explanation of Benefit should be the same dollar amount. EOBs can be inherently difficult to understand; if you need help call the insurance company.

High deductible health insurance plan - High deductible plans have a higher deductible, for example $4,000 or $5,000 per year, but may be less expensive to buy (they have a lower premium). With these types of plans, you may also be able to set up a pre-tax Health Savings Account (HSA) through your employer. You can use the HSA to help pay for your medical expenses now or in the future.

Out-of-pocket maximum - Out-of-pocket maximum is the maximum amount you would pay per year for medical expenses based on your insurance plan. Once you meet your out of pocket maximum, the health insurance company then pays for 100% of covered medical expenses. Yo uno longer have copays or coinsurance.

Health insurance premium - Your health insurance premium is the dollar amount you pay for medical plan benefits. This may be taken out of your paycheck if your employer provides health insurance, or the government may take it out of your social security if you have Medicare Part B. In 2024, the Part B premium is $174.70 a month. Part C premiums are billed through the private insurance company associated with your Medicare Advantage plan.

Preventive benefits - Preventive benefits are the doctor visits, health screenings, procedures and immunizations (vaccines), among other benefits, that are provided typically at no cost to you through your insurance. Check your plan benefits to determine your full benefits.

• Healthcare.gov. Accessed April 23, 2024 at  https://www.healthcare.gov/
• Understanding the Health Insurance Marketplaces. Kaiser Family Foundation (KFF). Accessed April 23, 2024 at  https://www.kff.org/understanding-health-insurance-marketplaces/

Medical Disclaimer

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• Deductibles

Copay, coinsurance and out-of-pocket maximum

Using your insurance plan may be easier when you understand common health care terms and what they mean. It also may make it easier to manage your health care costs when you learn what the cost terms mean for your wallet. So, let’s take a closer look and learn the difference between copays, coinsurance and out-of-pocket maximums.

What is a copay?

A copay (or copayment) is a fixed amount you may pay for a covered health care service, usually at the time you receive the service

How does a copay work?

You might remember times when you went in for a doctor visit and maybe paid a $15 or $20 copay before or after your visit. Copay amounts can vary depending on the provider and service. With health plans that have copays (not all do), you’ll know exactly what you have to pay ahead of time – which can help you budget your health care costs. For most plans, your copay does not apply toward your deductible. Also, some services may be covered at no additional cost, or $0 cost share, such as annual wellness exams and certain other preventive care services.

What is copay?

Video transcript

It’s a fixed amount you pay for health care services.

A copay is often paid right at the doctor’s office.

For example, a copay may be $15, $25 or another amount.

The amount can vary by the type of covered health care service.

Copays made clear

What is coinsurance?

Coinsurance is a percentage of the cost of a covered service. Until you reach your deductible, you’ll pay for 100% of out-of-pocket costs. After you meet your deductible, you and your insurance company each pay a share of the costs that add up to 100 percent. Typical coinsurance ranges from 20% to 40% for the member, with your health plan paying the rest. But cost-sharing percentages will vary depending on your plan.

How does coinsurance work?

If your doctor visit costs $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20 out of pocket. Your insurance would then pay the rest of the allowed amount ($80). Keep in mind, your coinsurance benefit doesn’t apply until after you’ve reached your deductible. Until then, you’ll need to pay 100% of the cost.

ON-SCREEN TEXT:

It’s your share, or % you pay, of the cost for covered services after you meet your deductible.

For example, if your office visit is $100 and your coinsurance is 20%, then you would pay $20.

Your health insurance plan would pay the other 80%.

Coinsurance made clear

What is an out-of-pocket maximum or limit?

You might have heard terms like out-of-pocket maximum or limit. But good news — they actually mean the same thing. So your out-of-pocket maximum or limit is the highest amount of money you could pay during a 12-month coverage period for your share of the costs of covered services. Typically, copays, deductible, and coinsurance all count toward your out-of-pocket maximum. Keep in mind that things like your monthly premium, balance-billed charges or anything your plan doesn’t cover (like out-of-network costs) do not.

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

How does an out-of-pocket maximum work?

If you meet your out-of-pocket maximum, your plan will usually pay 100% of your covered health care costs (up to the allowed amount ). Let’s say you have an annual out-of-pocket maximum of $6,000. That means once you’ve paid $6,000 out of pocket that year for your covered health care, usually including deductibles, copays and coinsurance, your plan will cover any future (covered, in-network) health care services during your coverage period.

The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan's allowed amount, you may have to pay the difference (balance-billed charge).

What is out of pocket limit?

What is an out-of-pocket limit?

It’s the maximum amount you could pay for covered services in a plan year.

After you meet your out-of-pocket limit, your health plan usually pays for 100% of the rest of your covered

services for the rest of the year.

That helps you plan ahead for health care costs.

Out-of-pocket limits made clear

Compare how copays and coinsurance work

There's a lot to understand when you're sorting out the difference between copays and coinsurance. Here's a quick view to help explain how these two types of payments work differently. 

Knowing how copays, coinsurance and out-of-pocket maximums work can help you add up your potential costs more accurately when you're planning for the year or when you're choosing your health plan during open enrollment . 

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• What's a deductible?
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• Manage & estimate your health care costs

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Health Care

Why an er visit can cost so much — even for those with health insurance.

Terry Gross

Vox reporter Sarah Kliff spent over a year reading thousands of ER bills and investigating the reasons behind the costs, including hidden fees, overpriced supplies and out-of-network doctors.

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. You wouldn't believe what some emergency rooms charge, or maybe you would because you've gotten bills. For example, one hospital charged $76 for Bacitracin antibacterial ointment. One woman who fell and cut her ear and was given an ice pack but no other treatment was billed $5,751. My guest, Sarah Kliff, is a health policy journalist at vox.com who spent over a year investigating why ER bills are so high even with health insurance and why the charges vary so widely from one hospital to the next.

Through crowdsourcing, she collected over a thousand ER bills from around the country. She interviewed many of the patients and the people behind the billing. She's reported her findings in a series of articles on Vox. She's also spent years reporting on the battle over health insurance policy. We'll get some updates on the state of Obamacare a little later in the interview.

Sarah Kliff, welcome back to FRESH AIR. Why did you want to do an investigation into emergency room billing?

SARAH KLIFF: You know, I wanted to do this because the emergency room is such a common place where Americans interact with the health care system. There are about 140 million ER visits each year. It's a place where you can't really shop for health care. You can't make a lot of decisions about where you want to go. So I think that is big-picture what got me interested.

Small picture was actually a bill that someone sent me almost three years ago now, where they took their daughter to the emergency room. A Band-Aid was put on the daughter's finger, and they left. And they got a $629 bill. And they said - you know, they - the parents sent this to me, saying, how could a Band-Aid cost $629? And I said, I don't know, but I'm going to find out. And that kind of opened up the door to this, you know, multi-year project I've been working on right now. It started with trying to figure out why a Band-Aid would cost $629.

GROSS: OK. So let's get to that $629 for treatment that was basically a Band-Aid placed on a finger. You investigated that bill.

KLIFF: Yes.

GROSS: Why'd it cost so much?

KLIFF: So what cost so much was really the facility fee. So this is a charge I hadn't heard about before as a health care reporter. This is a charge that hospitals make for just keeping their doors open, keeping the lights on, the cost of running an emergency room 24/7. So if you look at that particular patient's bill, the Band-Aid - you know, I hesitate to say only - but the Band-Aid only cost $7, which, as anyone who's bought Band-Aids knows, is quite expensive for a single Band-Aid.

But the other $622 of that bill were the hospital's facility fees for just walking in the door and seeking service. And these fees are not made public. They vary wildly from one hospital to another. And usually patients only find out what the facility fee of their hospital is when they receive the bill afterwards, like that patient, you know, that sent me this particular bill.

GROSS: And does the facility fee vary from facility to facility?

KLIFF: It does significantly. You know, I've seen some that are in the low hundreds. I've seen some that are in the high thousands. And it's impossible to know what facility fee you're going to be charged until you actually get the billing documents from your hospital. And if you try and call up a hospital and ask what the facility fee is, usually you won't get very far.

So it's this fee that, from all the ER bills I've read, is usually the biggest line item on the bill. But it's also one that is very, very difficult to get good information about until you've already been charged.

GROSS: So you're paying the facility fee to basically share in the cost of running the emergency room.

KLIFF: Yes, that's how hospital executives would describe the fee.

GROSS: But you don't know that when you're going to the emergency room.

KLIFF: You don't, no. And you don't know how much it'll be. You don't know how it's being split up between different patients. You don't know any of that.

GROSS: So is this also why one bill had $60 for the treatment of ibuprofen and another $238 for the treatment of eyedrops?

KLIFF: Yeah. And, you know, this is something I see all the time reading emergency bills - I've read about 1,500 of them at this point - is that things you could buy in a drugstore often cost significantly more in the emergency room. And the people I talked to who run hospitals will say this is because they have to be open all the time. They have to have so many supplies ready.

But I think one of the things that I find pretty frustrating is, you know, patients aren't usually told, we can give you an ibuprofen here, or you can pick some up at the drugstore if you leave, and the cost will be a fraction of what we would charge you here. That information often isn't conveyed to patients who are well enough, you know, to go to a drugstore on their own. But it's just huge variation for these simple items.

One place I see this a lot is pregnancy tests. If you're a woman who's of childbearing age, you go to the emergency room, they will often want to check if you're pregnant. I've seen pregnancy tests that cost a few dollars in emergency room. The most expensive one I saw was over $400. I believe that was at a hospital in Texas. It's just widespread variation for, you know, some pretty simple pieces of medical equipment.

GROSS: I want to get back to the $60 ibuprofen. Is that - does that include the facility fee? Or is that just for the ibuprofen, and the facility fee is separate?

KLIFF: That's just for the ibuprofen. The facility fee is totally separate.

GROSS: So how do they justify that?

KLIFF: They say they have to stock, like, a wide array of medicine, so they have to have everything on hand from ibuprofen, from, you know, expensive rabies treatments - I've talked to a lot of people who've been to the emergency room for exposure to bats and raccoons - and that they need to have all these things in stock. And, you know, one of the things you pay for at the emergency room is the ability to get any medication at any hour of the day right when you need it. I don't necessarily buy that explanation, to be clear. That's what I've heard from hospital executives.

I think it's pretty telling that ibuprofen has a very, very different price depending on which emergency room you go to. The fact that there's so much widespread price variation suggests to me that it's not just the cost of doing business driving it, that there's also business decisions being made behind ibuprofen that are driving the prices different hospitals are setting.

GROSS: Now, of course, trips to the emergency room aren't always as simple as getting a Band-Aid or ibuprofen or some eyedrops. I want you to describe the case of a young man who was hit by a pole on a city bus in San Francisco.

KLIFF: Yeah. So this patient, his name is Justin. He was a community college student in northern California, was walking down a sidewalk in downtown San Francisco one day. And there was a pole hanging off the back of the bus that wasn't where it's supposed to be. It essentially flew off the back of the bus, hit him in the face and knocked him unconscious.

And the next thing he knows, he's waking up at Zuckerberg San Francisco General, which is the only Level I trauma center in the city. He ends up needing a CT scan to check out some brain injuries. He needs some stitches. And then he's discharged. He ends up with a bill for $27,000.

But, you know, as I began figuring out through my reporting, San Francisco General does not contract with private insurance, and they end up pursuing him for the vast majority of that bill. He has $27,000 outstanding. And somewhat ironically, San Francisco General, it is the city hospital. It is run by the city of San Francisco. So this student is hit by a city bus, taken by an ambulance to the city hospital and ends up with a $27,000 bill as a result.

GROSS: So did he have insurance?

KLIFF: He did. He had insurance through his dad.

GROSS: So why doesn't Zuckerberg San Francisco General Hospital contract with private insurers?

KLIFF: So what they have told me when I've talked to some spokespeople there is that they are a safety net hospital, and that is, you know, definitely true. They generally serve a lower-income, often indigent population in San Francisco that would have trouble getting admitted and seeking care at other hospitals in the city. So they have told me that their focus is on serving those patients and that therefore, you know, they're not going to contract with private insurance companies.

The thing I found a little bit confusing about that, though, is there are lots of public hospitals, say, that, you know, also serve low-income populations. And some of them for their inpatient units, you know, for their scheduled surgeries, they're not going to contract with private insurance because they want to make sure beds are available for the publicly insured folks and people on Medicaid and Medicare.

But when it comes to the emergency room, you know, every other public hospital I was in touch with would contract with private insurers there because people don't decide if they're going to end up in the emergency room. So, you know, that's the justification they offered, that it is a hospital meant to serve those with public insurance. But it is not something you see public hospitals typically doing.

GROSS: Isn't - I think legislation was proposed in California to change that. Did that pass?

KLIFF: It's still pending in the California State Assembly. And the hospital has also promised to reform its billing practices, although we haven't seen what exactly their new plan is yet.

GROSS: So the position that Justin was in is that, like, he's unconscious. He's not asking to be taken anyplace. (Laughter) But he's unconscious. He's taken to the emergency room and ends up getting this $27,000 bill. I mean, that just seems so unfair, especially since he has insurance.

KLIFF: Yeah.

GROSS: Like, it's supposed to cover him for things like that (laughter).

KLIFF: Yeah. You know, there's one other patient who kind of makes this point really well who was also seen at San Francisco General. Her name is Nelly. And she fell off a climbing wall and, somewhat amazingly, you know, turns out she had a concussion. But one of the first things she does is she calls her insurance's nursing hotline to ask, should I go to the ER?

And they say yes. And she says, can I go to Zuckerberg San Francisco General? It's the closest. They say, no, don't go there. It's not in network. Go to another hospital. She gets to the other hospital, but the other hospital won't see her because she's a trauma patient. She fell from a really high height. And San Francisco General is the only trauma center in San Francisco. So she tries to go to an in-network hospital. She's then ambulance-transferred to Zuckerberg San Francisco General, and she ends up with another bill over $20,000 that the hospital was pursuing from her until I started asking questions from it, and the hospital ultimately dropped the bill.

But I think it's just such a frustrating situation for someone like Justin, for someone like Nellie (ph). They're either shopping for this good unconscious, they're really trying to do the right thing, and the health care system is just so stacked against the patient. It's so stacked for the hospital to be able to bill the prices that they want to bill.

GROSS: So apparently, the moral of the story is if you want to challenge your emergency room bill, you should get Sarah Kliff to write about you. (Laughter).

KLIFF: It's - (laughter). That's what some people have said. But there's only one of me, and there's about 2,000 bills in our database. And, you know, we have had over $100,000 in bills reversed as a result of our series. But I don't think it's a great way to run a health care system where we just, you know, the people who get their bills reversed are those who are lucky enough to have a reporter write a story about them.

GROSS: Yes. Agreed. Let me reintroduce you. If you're just joining us, my guest is Sarah Kliff. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy actually affects people.

So we're going to take a short break, and then we'll talk more about emergency billing. And then later, we'll talk about what's left of Obamacare, and what the president and Congress and candidates are saying about health care, after this break. This is FRESH AIR.

(SOUNDBITE OF ALEXANDRE DESPLAT'S "SPY MEETING")

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff. We're talking about emergency room billing and why it's so unpredictable and often so incredibly high. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy affects people.

So we were talking about the hidden facility fee, which most people don't know exists, and is responsible for a large chunk of a lot of emergency room bills. There's also, like, a trauma unit fee. It's a similar hidden fee in hospitals that have trauma centers in their emergency rooms. So explain the trauma fee and how that kicks in.

KLIFF: Yeah. This is something I also had never heard of till I started reading a lot of emergency room bills, and this is the fee that trauma centers charge for essentially assembling a trauma team to meet you when you're coming in and those folks out in the field, maybe the EMTs, for example, have determined that you meet certain trauma criteria.

So I've talked to people who have been charged trauma fees who were in serious car accidents. One case was a baby who fell from more than 3 feet, and that's considered to trigger a trauma activation. So this is essentially the price for having a robust trauma team - a surgeon, an anesthesiologist, nurses - all at the ready to receive you when you get to the hospital.

And again, these fees can be pretty hefty. San Francisco General, which, I've done the most reporting on their billing, you know, they can charge up to $18,000 for their trauma activation services. I wrote about one family who was visiting San Francisco from Korea when their young son rolled out of the hotel bed. They were nervous. They didn't know the American health care system well. So they called 911, which sent an ambulance, brought him over to the hospital. Turns out, he was fine. They gave him a bottle of formula. He took a nap and went home.

And then a few months later, they get an $18,000 charge for the trauma team that assembled for when that baby came to the hospital. And these are another, you know, pretty significant fee that, again, you don't really know about. You have no idea that the trauma team is assembling to meet you when you're coming into the hospital. You just find out after the fact. And you also have no say in the decision to assemble trauma. That's really left up to the hospital, not the patient.

GROSS: So I'm going to have you compare two possibilities. You go to an emergency room, and the bill is very high. There's two people who have the same problem who go to the emergency room. One of them has a copay. One of them has a high deductible that they haven't paid off yet. How are they treated differently, in terms of what they're billed for the emergency room visit?

KLIFF: Well, the person with the deductible will likely be billed significantly more. You know, if they're just, let's say, at the start of the year, they are going to essentially have to bear the costs of that emergency room visit up until the point they hit their deductible and the insurance kicks in, whereas the person who has a co-payment, they're just going to have to pay that flat fee and, you know, probably not worry about paying more, but there's often surprise bills lurking in the corner that could affect both of those patients as well.

GROSS: Like what?

KLIFF: So one of the most common things we see is out-of-network doctors working at in-network emergency rooms. So you know, you have an emergency, you look up a hospital, you see their ER is in network, so you go there. It turns out that emergency room is staffed by doctors who aren't in your insurance. There's pretty compelling academic research that suggests 1 in 5 emergency room visits involves a surprise bill like that one.

GROSS: That seems so unfair. How are you to know - if you're choosing a hospital that's in network, how are you to know whether the doctor treating you is in network or not?

KLIFF: You know, you really - there isn't a great way to tell, to be honest. This is - you know, when I had to go to the emergency room over the summer, you know, this is something I worried about. You know, I was seeing a doctor who worked for the hospital, but they were sending off my ultrasound to be read by a radiologist who I was never going to meet. I couldn't ask them if they were in-network. I just kind of had to cross my fingers and hope for the best, and luckily, I didn't get a surprise bill.

But I've talked to multiple patients who, you know, tried to do their research, who thought they were in network, only to get a bill, often for thousands of dollars, after leaving the emergency room, from someone who, you know, never mentioned to them, hey, I'm not in your network like this hospital is.

GROSS: So the bill that you'd get would be for the difference between what you pay when somebody is - when a doctor's in network and what you pay when they're not in network?

KLIFF: Yeah, often it's just what that out-of-network doctor wants to charge. So a good example of this is a patient I wrote about in Texas named Scott (ph), who was attacked in downtown Austin, left on the street unconscious, some bystander called him an ambulance, and he woke up at a hospital. And one of the first things he does, because this is the United States, is he gets on his phone and tries to figure out which hospital he is at, and, you know, is that in his insurance network? And he finds out - good news - it is. And a surgeon comes by, tells him he's going to need emergency jaw surgery because of the attack that happened.

So he says, OK. You know, he's not really in a place to go anywhere. Gets the surgery. Goes home. A few weeks later, he gets an $8,000 bill from that oral surgeon, who the insurance companies paid a smaller amount. The oral surgeon didn't have a contract with the insurance and said, you know, I think my services are worth a lot more, so pursued the balance of the bill from Scott.

GROSS: I have to say, I mean, that does seem unfair to the patient because they haven't been informed. They can't make a choice about it if they don't know. And, like, $8,000 is a lot of money.

KLIFF: Yeah. And I think, you know, even more, let's say he did say he was out of network. It kind of puts the patient in an unfair situation, too. You know, one of the things we talk about a lot in health policy is, what if we had more transparency? What if we let patients know the prices? What if we let patients know who is in and out of network? And that - it would be a good step.

But, you know, I think with someone like Scott, sitting in a hospital with a broken jaw, there's not much you can do with that information. He doesn't have, you know, the ability to go home, like, research, like, make an appointment with a new surgeon. So, you know, it'd be great if he knew that the doctor was out of network. It'd be even better if he had some kind of protections against those type of bills.

GROSS: What kind of protection could there be?

KLIFF: So we're actually seeing a lot of action on this in Congress. There's some pretty strong bipartisan support for tackling this specific issue and essentially holding the patient harmless. When there is a situation like Scott's, for example, where there's this $8,000 bill, that's really a dispute between a health insurance company and a doctor, where the doctor says, I want more money, the insurer says, I want to pay you less money. And what Congress wants to do - what a few states have already done with their laws - is said, you can't go to the patient for that money. You, the hospital, and you, the health insurance company, you have to get down to a table and work things out together.

And some state laws will set certain amounts that are allowed to be charged, other ones will force the insurance company and the hospital into an arbitration process. But the general concept is to take the patient out of this billing situation because, like you said, Terry, they really aren't in a position to negotiate. They aren't in a position to shop. They shouldn't be the ones who are left holding the bag at the end of the day.

GROSS: My guest is Sarah Kliff. She covers health policy for Vox. After a break, we'll talk more about why ER bills can have some unpleasant surprises, and she'll give us an update on Obamacare. And Maureen Corrigan will review two books about forgotten stories from Hollywood. I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF JESSICA WILLIAMS TRIO'S "KRISTEN")

GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with journalist Sarah Kliff, who covers health policy and how it affects people for Vox. For the past year and a half, she's been writing about why emergency room visits can be so expensive and the pricing so secretive and mysterious, as well as inconsistent from one hospital to the next. She collected over 1,000 bills and tracked down stories behind the billing. She interviewed many of the patients and the people behind the billing to decipher why ER bills can have some surprise costs.

Here's another surprise that often awaits people who go to emergency rooms - some insurance plans only cover true emergencies, and whether it is a true emergency is sometimes determined after the diagnosis is made. So how are you supposed to know before the diagnosis whether you're going to be categorized as a true emergency or not? Like, if you go to the hospital, you don't know if you have a broken bone or not.

KLIFF: Right.

GROSS: Somebody needs to X-ray it and tell you.

KLIFF: Right. The whole point you go to the emergency room is to help them figure out what the emergency is and what treatment you need. This is a policy that the insurance company Anthem has been pioneering for a few years. It's been in Kentucky. It's been in Georgia - a few other states. And, you know, I wrote about one patient out in Kentucky named Brittany, who - she was having really severe abdominal pain. She called her mom who is a nurse, and the nurse said, that might be appendicitis. You've got to get to the emergency room. Turns out it wasn't appendicitis. It was an ovarian cyst. She got it treated elsewhere later down the line.

And Anthem, you know, sent her a letter saying, we're not going to cover that visit because it was not a true emergency. She appealed it. Her appeal was denied. This is another one where, once I started asking them about it, the bill suddenly disappeared. But - and it seems like as Anthem has gotten more attention for this policy - they haven't announced it publicly, but some pretty compelling data The New York Times got their hands on suggest they've backed off this policy.

But it's just, you know - there are so many traps you can fall into going into an emergency room. It just feels like you're walking into this minefield, and this is kind of one of those mines that's lurking in there.

GROSS: Hospital pricing and emergency room pricing seems to vary so much from hospital to hospital. Are there, like, national guidelines that help determine what a hospital or a hospital emergency room charges for services? I mean, who decides, and why is there such a variation?

KLIFF: So hospital executives get to decide, and I think that is why there is such variation. There aren't really guidelines that they're following. You know, one thing you could do as a hospital executive - you could look at what Medicare charges - those prices are public - and, you know, maybe use that as a benchmark. There are some databases. There's one called FAIR Health, for example, where you could look and see, you know, some information on what local prices typically are. But in terms of, you know, what you want to charge, that's kind of up to you as someone running a hospital.

One of the things that's really, really unique about the United States, compared to our peer countries, is that we don't regulate health care prices. Nearly every other country in the developed world - they see health care something as, you know, akin to a utility that everyone needs, like electricity or water. It's so important that the government is going to step in and regulate the prices. That doesn't happen in the United States. You know, if you're a hospital, you just choose your prices. And, you know, that is, I think, why you see so much variation and why you see some really high prices in American health care.

GROSS: So what advice do you have for people who actually need an emergency room and don't want to get hit with a shocking bill afterwards?

KLIFF: Yeah, this is, you know, one of those questions - it just makes me a little frustrated that - 'cause this is the most common question I get - right? - is, how do I - how do we - how do I prevent a surprise bill? And I find it kind of upsetting that, you know, it has to be on the patient because honestly, there really isn't a great way to do this. I've talked to so many patients who tried so hard to avoid a big medical bill and weren't able to.

You know, there's certain things, yes, you can do. You can look up the network status of your hospital. You can try and badger each doctor you see about whether they are in network. You can try to be a really proactive patient, but I think that's just such a huge burden on people who are in, like, really emergent situations. And some people don't have that opportunity, you know, like Justin Zanders, the guy we were talking about earlier who was taken to a hospital while he was unconscious. I cannot think of anything he could've done to avoid that bill. It just was not possible.

GROSS: So your advice is, good luck.

KLIFF: Short of that, I mean, good luck. You know, I'm actually in the middle of reporting a story right now about people who have successfully negotiated down their bills. And, you know, you can certainly - if you do end up with a surprise bill, you can call up the hospital, see if there's a discount. Sometimes there will be. Sometimes there won't. You can call again. Customer service representatives - different ones - often offer you different discounts, I've learned from interviewing patients. You can ask for a prompt pay discount if you pay right away.

You can - you know, one health attorney who negotiates these a lot on behalf of patients - he says one of his favorite tactics is to choose the amount you want to pay; send a check with that amount; and in the note, write, paid in full; and hope they don't come after you after that. I have no idea if that works or not, but he says it works for his patients. But it's a mixed bag. And at the end of the day, the hospital has all the power. You can ask for discounts. You can ask nicely. You can ask angrily. It's up to the hospital if they want to grant you that or not.

GROSS: So what is the status of Obamacare now? You know, Republicans promised to repeal and replace. That didn't work out. So have Republicans given up on repeal and replace?

KLIFF: For the time, it seems pretty clear that repeal and replace is dead on arrival, especially with Democrats taking control of the House this year. Those proposals aren't being talked about as much. They're not really going anywhere. The one big thing we did see Republicans succeed at is repealing Obamacare's individual mandate, the requirement that all of us carry health insurance. That happened as part of the big tax package that passed at the end of 2017.

So we've seen, you know, President Trump, for example, essentially declare victory, declare that repealing the individual mandate is repealing Obamacare, so we're good on that goal. But, you know, generally, Obamacare is still standing. There are millions of people getting their coverage through the Affordable Care Act still today.

GROSS: So now that there's no individual mandate, conservative attorney generals are challenging Obamacare - the Affordable Care Act - and saying it's no longer constitutional after Congress's repeal of the individual mandate. Could you explain that?

KLIFF: Yeah, so this is a challenge that's come up through the courts in the past few months. Obamacare is constantly being challenged in court. It's been through multiple Supreme Court suits. This one - you know, it's a multiple-part argument, so I'll try my best to walk through it.

KLIFF: So essentially, it starts with the fact that the individual mandate - they weren't quite able to repeal it for boring technical reasons. But what they were able to do is change the fee for not having health insurance from $700 to $0. So it - in all practical terms, it feels like repealing it because there is no fee for not carrying health insurance. The individual mandate was upheld as a tax when the Supreme Court said, yes, this is constitutional. The government has a right to tax people. Now that there is no fee associated with not carrying health insurance, the conservative attorneys general who are bringing this case argue that it's not a tax anymore, and therefore, it is not constitutional. That whole defense that John Roberts wrote in 2012 is moot. So that's the first part of it.

They go even further and say the individual mandate is so core to the Affordable Care Act, it is not severable. And if you, the courts, rule the individual mandate unconstitutional, then you need to rule all of Obamacare unconstitutional. And the first judge who heard this case - he is a, you know, judge in a district court in Texas. He agreed with them. He agreed that - first step - that the individual mandate is no longer constitutional. And second step, that means that the entirety of Obamacare has to fall. This is now being appealed up to the 5th Circuit Court of Appeals.

And I will say there are a lot of critics of this case. There are a lot of people who were parties to previous Supreme Court challenges to Obamacare who think this is a bad legal argument and that it will not succeed. But it is already, you know, gone through the district court level. It's moving up to the appellate court level. It is something that is in the mix that could become a threat to the Affordable Care Act.

GROSS: Well, if it goes to the Supreme Court, it would be very interesting to see what Justice Roberts says since he voted for the ACA, saying that the individual mandate was a tax.

KLIFF: Yeah. You know, and I think where some legal scholars would see it shaking out is that the - someone like John Roberts, he might agree, OK, yeah, the individual mandate is unconstitutional, but would not make the leap to the second half of this, that the rest of the law has to fall.

I think one of the most compelling arguments against this case is that Congress knew what they were doing when they repealed the individual mandate. You know, they had the opportunity to repeal Obamacare. They didn't. They'd specifically took aim at this one specific part. So it feels like it might be a bit of a reach to argue that what Congress really meant to do was repeal all these other parts of the Affordable Care Act. But, you know, the Supreme Court is changing. We have a new justice. You know, we have a lot in the mix. So it's always an open question of how a decision like this could go.

GROSS: So correct me if I'm wrong here - the Department of Justice has sided with the conservative attorneys general who are challenging Obamacare, saying it's no longer constitutional, and I think that the Justice Department is also asking the judge to strike down the ACA's mandatory coverage of pre-existing conditions.

KLIFF: Yeah, that's right. So it's a kind of unusual situation. Usually, it's the Justice Department that is going to defend a federal law in court. But, you know, given the Trump administration's opposition to the Affordable Care Act, they have decided to side with the conservative attorneys general. They have a slightly different argument. They don't think all of Obamacare should fall if the mandate falls, but they do think some big parts, like you mentioned, the protections for pre-existing conditions, should be ruled unconstitutional if the mandate falls.

So this has led to a bit of an unusual situation where you've had this coalition of Democratic attorneys general step in and take over the case, basically saying that the federal government is going - is not going to defend the Affordable Care Act. We are going to defend the Affordable Care Act. So you have this coalition of Democratic attorneys general, led by the attorney general of California, stepping in and, you know, offering a defense as this case works its way up through the court system.

GROSS: Let's take a short break here, and then we'll talk some more. If you're just joining us, my guest is Sarah Kliff. She's senior policy correspondent at Vox, where she focuses on health policy. And she hosts the Vox podcast "The Impact," about how policy actually affects people. We'll be right back. This is FRESH AIR.

(SOUNDBITE OF THE WEE TRIO'S "LOLA")

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff, senior policy correspondent at Vox, where she focuses on health policy.

Do you think health insurance is shaping up to be a big issue in the 2020 campaign?

KLIFF: I do, and I think it's going to be a big issue both in the primary, where you're already seeing candidates get pressed on, should we still have private health insurance, and giving pretty different answers to that question.

And then I think one of the things you're also going to see is whoever is the Democratic nominee is probably going to run on Obamacare. They are going to point at the fact that President Trump tried to repeal the Affordable Care Act. That's pretty different than, you know, the 2012 election, where Democrats were pretty scared to run on Obamacare. It still wasn't popular. The benefits hadn't rolled out. In this past midterm and now again in the 2020 election, it seems pretty clear that Democrats are pretty excited to point out that Republicans wanted to repeal Obamacare. So I think it really will come up.

GROSS: What are some of the biggest falsehoods you've heard from politicians about health insurance costs or health insurance policy?

KLIFF: You know, one of the ones that's come up a lot is actually around the role of private health insurance. So I've - I don't know if it counts as a falsehood, but I think it's a bit of a misunderstanding of how health insurance often works is, you know, when I talk to single-payer supporters, most of them want to eliminate private insurance completely. They just don't think there is a role for it in the health care system.

And one of the things I think that's actually pretty interesting, when you look at any other country - you look at Canada, you look at the U.K., you look at France, which all have national health care systems - all of them have a private health insurance market, too. There are always some kind of gap in the system that the public insurance can't cover, where the government step - where the private industry steps in and offers coverage. In Canada, for example, their public health plan doesn't cover prescription drugs, so two-thirds of Canadians take out a private plan, often through their employer, like us, to cover prescription drugs, to cover their eyeglasses, to cover their dental. So I think that's a confusion I see a lot in the "Medicare for All" debate coming up right now.

I think the other thing I see a lot of confusion around - and we've talked about this a little bit with emergency room billing - is the role of transparency in health care. I see a lot of, you know, if we just made the prices public, like, that is what we need to do to fix the system, and I think that really misses the fact that, even if the prices were public, health care is so different from everything else we shop for. It might be - I think it is the only thing we purchase when we are unconscious.

GROSS: (Laughter).

KLIFF: And when you're unconscious, you're not really going to be great at price shopping. So I see that as, you know, a halfway solution that I often hear talked about here in Washington that would be great but is not going to suddenly result in, you know, prices dropping because they've been exposed in a spotlight.

GROSS: Is there a country that you think has a good health care model that we could borrow?

KLIFF: Oh, yeah. I've been thinking about this a lot lately actually. So I've gotten very interested in the Australia health care system, which is a little far away. But I think they're a really interesting model because they have a public system, everyone's enrolled in it, but they also really aggressively try and get people to buy a private plan, too, and that private plan will get you sometimes faster access to doctors, maybe a private room at a hospital.

It's really hard for me to see the U.S. creating a health care system, similar to Canada's actually, where you can't buy private insurance, where if you're rich or you're poor, everyone waits in the exact same queue, you can't jump to the front of the line. Because I think wealthier Americans have gotten so used to having really good access to health care that they would be very upset with a system like that.

I think Australia is a kind of interesting hybrid between, you know, where we're at in the U.S. right now and what Canada is like, where it says, yes, we're going to create a public system for everybody, but we're also going to have these private plans that compete against the public system. So I've become increasingly, you know, interested in how Australia's system works. And they have - about 47 percent of Australians are buying a private plan to cover the same benefits that the public plan does.

GROSS: So it's not supplemental. It's instead of.

KLIFF: Right. So it's very different from Canada. So in Canada, you can buy complementary insurance, you know, to cover the benefits the public plan doesn't but the government expressly outlaws supplemental insurance. You know, like, what people buy here to cover the gaps in Medicare, that is not allowed. You cannot buy your way to the front of the line in Canada.

One of my favorite sayings about the Canadian health care system is from a doctor in a book I read about Canadian health care is they said, you know, we're fine waiting in lines for health care in Canada as long as the rich people and the poor people have to wait in the exact same line. Their system is all about equality. And I just don't know that we're at a place as a country where we value the same sort of equality in our health care system.

GROSS: Is there any developed country around the world that has a system similar to ours with all these competing insurance companies and, you know, some government plans and, like, a thousand different bureaucracies that doctors have to deal with and that patients have to deal with?

KLIFF: Absolutely not. There's nothing like it. I mean, our system is so unique. I'd say the closest but it's not even close are a few countries that have national health care systems, but they do it through tightly regulated private health insurance plans. So if you look at, like, Netherlands or Israel, there isn't a government-run plan. Instead, in both countries, you actually have four tightly regulated health insurance plans that compete against each other for the citizens' business. I guess that's the closest, but that is so different from what we have here right now. There's really nothing like it in any developed country.

GROSS: Sarah Kliff, thank you so much for talking with us.

KLIFF: Well, thank you for having me.

GROSS: Sarah Kliff covers health policy for Vox, where you'll find her series about emergency room bills. After we take a short break, Maureen Corrigan will review two books about forgotten stories from Hollywood. This is FRESH AIR.

(SOUNDBITE OF GEORGE FENTON AND PHILHARMONIC ORCHESTRA'S "MISS SHEPHERD'S WALTZ")

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Will Medicare cover the costs of my doctor visits?

If you’re on Medicare, you might expect that the program would cover doctor visit costs. Medicare may cover doctor visits if certain conditions are met, but in many cases you’ll have out-of-pocket costs, like deductibles and coinsurance amounts.

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Doctor visits: a general rule

No matter what kind of  Medicare coverage  you may have, it’s important to understand that your doctor accept Medicare assignment. That’s an agreement the doctor has with Medicare that the doctor will accept the Medicare-approved amount as payment in full for a given service and won’t charge you more than the coinsurance payment and deductible.

Does Original Medicare cover all doctor visits? 

Original Medicare is made up of Part A (hospital insurance) and Part B (medical insurance). Generally, Part B covers doctor visits – even when you’re in the hospital, where a lot of your care is covered under Part A. A deductible and/or coinsurance amount may apply.

Does Medicare Part B cover doctor visits?

Many Medicare-covered services under Part B come with a 20% coinsurance amount after you’ve paid your Part B deductible. For example, if the Medicare-approved amount for a doctor visit is $100, and you’ve already paid your Part B deductible, you’d pay $20 in coinsurance (20% of $100) for the doctor visit. If the doctor orders tests, those may be extra.

Did you know you might be able to buy insurance that may cover these out-of-pocket costs for doctor visits? Read about Medicare Supplement (Medigap) insurance plans below.

What is the copay for a doctor visit with Medicare coverage?

Medicare costs typically vary based on what coverage and services you receive and what providers you visit. When it comes to your copay, Medicare Part B usually covers 80% and you pay 20% of the cost for each Medicare-covered service such as a doctor’s visit or item after you’ve paid your Part B deductible. 

Doctor visits and Medicare Supplement insurance

It may be useful to know that Medicare Supplement insurance plans help pay for some Medicare Part A and Part B out-of-pocket  Medicare costs . Medicare Supplement insurance plans generally pay at least part of your coinsurance amounts for Medicare-covered doctor visits. Most standardized plans typically pay the full Part B coinsurance amount.

For example, suppose you had a doctor visit, and the doctor ordered an MRI (magnetic resonance imaging) screening. Let’s say the Medicare-approved costs were $100 for the doctor visit and $900 for the MRI. Assuming that you’ve paid your Part B deductible, and that Part B covered 80% of these services, you’d still be left with some costs. In this scenario, you’d typically pay $20 for the doctor visit and $180 for the x-rays.

If you had Medicare Supplement Insurance Plan M, those Part B out-of-pocket  Medicare costs  might be completely covered so you would pay nothing. There are other Medicare Supplement Insurance Plans that can cover out-of-pocket costs, Plan M is just one of them. Of course, Medicare Supplement insurance plans come with a monthly premium. But if you have many doctor visit costs, you might want to  learn more about Medicare Supplement insurance plans .

Some doctor visits may have no out-of-pocket cost to you

You may be asking yourself, “Is everything covered with Medicare?”   If you have Medicare Part B, or if you’re enrolled in a Medicare Advantage plan, you may get certain doctor visits and preventive screenings with no out-of-pocket cost to you such as:

• A review of your medical history
• A simple vision test
• Certain disease prevention/detection screenings
• A depression screening
• Certain shots if needed
• Measurement of your vital signs (such as height, weight, and blood pressure)
• A written plan outlining what additional screenings, shots and other preventive services you need.
• Annual wellness visit . After the first 12 months of coverage, Medicare covers a wellness doctor visit once a year. The doctor will review your medical history; update your list of medications; measure your height, weight, blood pressure and other vital signs; and discuss your health status with you.

Medicare Part B may cover other doctor visits and preventive screenings. For example, you’ll get a doctor visit every year to evaluate and help reduce your risk of cardiovascular disease. There typically is no out-of-pocket cost for this visit.

Be aware that if your doctor orders other tests or medical services during your doctor visit, you might need to pay a deductible amount or coinsurance. Medicare might not cover certain tests or services at all. You might want to find out ahead of time whether the services are covered.

Doctor visits and Medicare Advantage

Perhaps you chose to enroll in a Medicare Advantage plan as an alternate way to receive your Original Medicare benefits. Your doctor visits may have different out-of-pocket costs than you’d pay under Original Medicare.

Medicare Advantage plans  are offered by private insurance companies contracted with Medicare. Some plans have monthly premiums as low as $0, but they generally have other costs. Coinsurance, copayments, and deductibles may vary from plan to plan – as will as premiums.

You’ll still have to pay your Medicare Part B premium if you sign up for a Medicare Advantage plan – in addition to any premium the plan may charge.

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*Top considerations based on eHealth original February 2023 study of Medicare Consumer Sentiments. 1 The nation's top plans based on Kaiser Family Foundation's 2023 Update and Key Trends report ; analysis of 2023 CMS Medicare Advantage enrollment by firm. †1.3 million people used eHealth to sign up for an insurance plan (including Medicare, Individual and Family, Ancillary, and Small Business plans) based on eHealth’s 2022 year's end estimated membership as reported on pg 53 of the eHealth® 2022 Annual Report . [1] “Top Picks” are calculated by eHealth’s proprietary PlanPrescriber technology. By using a customer’s profile information, and data attributes they’ve provided through the website or an eHealth licensed insurance agent, customers can see up to three plan recommendations. A “Top Pick” is a plan that meets the most criteria established by the customer while a “Great Pick” meets slightly less criteria. Insurance Ad - No Government Affiliation. This ad is not from the government. It’s from eHealth, an independent Medicare insurance agency selling plans from many insurance companies. The Medicare plans represented are PDP, HMO, PPO or PFFS plans with a Medicare contract. Enrollment in plans depends on contract renewal. Enrollment in a plan may be limited to certain times. Eligibility may require a Special or Initial Enrollment Period. eHealth and Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. We do not offer every plan available in your area. Currently we represent 193 organizations which offer 4,264 products in your area. Please contact Medicare.gov , 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Benefits may vary by carrier and location. Deductibles, copays, coinsurance may apply. Limitations and exclusions may apply. By initiating a chat or scheduling a call you are agreeing to be contacted by a licensed sales agent by email, text message, or phone call to discuss information about Medicare insurance plans. This is a solicitation for insurance. Standard messaging rates may apply. eHealth's website is operated by eHealthInsurance Services, Inc., a licensed health insurance agency doing business as eHealth. The purpose of this site is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. eHealth is a free service with no obligation to enroll. Your information and use of this site is governed by our most recent Terms of Use and Privacy Policy .

What is a copay & when do you have to pay it?

A set amount that you pay any time you receive certain medical services

Updated April 30, 2021 | 4 min read

Policygenius content follows strict guidelines for editorial accuracy and integrity. Learn about our editorial standards and how we make money .

Table of contents

Copays vs coinsurance

Copays vs deductible, copays and out-of-pocket max, copays with medicare and medicaid.

A copay is a flat fee that you pay when you receive specific health care services, such as a doctor visit or getting prescription drugs . Your copay (also called a copayment) will vary depending on the service you receive and your health insurance plan, but copays are typically $30 or less.

Copays are a form of cost sharing. Insurance companies use them as a way for customers to split the cost of paying for health care. Copays for a particular insurance plan are set by the insurer. Regardless of what your doctor charges for a visit, your copay won't change.

Key takeaways

A copay is a flat fee you pay whenever you receive certain health care services or get prescription drugs

Copays may apply before and *after* you hit your deductible

A copay is different from coinsurance, which only applies after reaching your deductible and is the percentage of your final bill that you pay

Not all services require a copay — preventive care usually doesn’t — while the copay for other medical services may depend on which doctor you see or which medicine you use. In particular, certain insurance plans charge more to visit a specialist physician instead of your primary care physician. Name brand prescription medicine usually has a higher copay than generic versions.

As a general rule, health insurance plans with lower monthly premiums (the amount you pay each month in order to have health insurance) will have higher copays. Plans with higher premiums usually have lower copays.

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Copays and coinsurance are two ways that insurance companies share costs with customers, but they differ in both how and when they apply.

As mentioned, a copay is a set amount of money that you pay when you receive a certain service. The amount of your copay varies based on the service. An office visit for your primary care physician may have a $20 copay, while filling an order for prescription drugs may have a $25 copay. No matter how much the doctor or provider charges for the service your copay is the same.

On the other hand, coinsurance is charged as a percentage instead of a flat fee. For example, let’s say you have coinsurance of 20%. That means you need to pay 20% out of pocket, and then your insurance will cover the other 80% of the bill. (This is also referred to as 80/20 coinsurance.) Your coinsurance will also apply in addition to your copay.

Another important difference is that copays may apply regardless of whether you’ve met your deductible, but you only pay coinsurance after you’ve reached your deductible or if you see an out-of-network provider. The major exception is if you have a zero-deductible plan, which will always require you to pay coinsurance.

Before you hit your deductible, you will have to pay out of pocket when you go to the emergency room or if you require urgent care, like a medical procedure. (If you need care to treat a life threatening situation, your insurance will cover the cost because of the essential health benefits that Obamacare requires insurers to cover.)

The following table highlights some key differences between a copay and coinsurance .

Outside of clinic visits and preventive care, certain medical procedures are subject to a deductible. Your health insurance deductible is the amount of your own money that you need to pay for those procedures before your insurance company will step in to pay for some of your medical expenses.

A high deductible means you pay more yourself before your insurance steps in. What expenses count toward meeting your deductible may vary by plan, but copays do not usually count toward your deductible .

Learn more about deductibles .

A high deductible means you pay more yourself before your insurance steps in. What expenses count toward meeting your deductible may vary by plan, but copays do not usually count toward your deductible.

Your out-of-pocket maximum, also called your out-of-pocket limit , is the maximum amount you will have to pay on your own for medical expenses if you have health insurance. Once you hit that spending amount, your insurer will take over to cover the rest of your costs for the calendar year. Your spending towards the limit will reset once a new year starts.

Copays do count toward your annual out-of-pocket maximum since they are all out-of-pocket expenses . You don’t usually have to make copays after you hit your maximum, but this varies by plan. Check the details of your specific plan for more information.

Learn more about what counts toward your out-of-pocket maximum .

If you have Medicare , the federal health insurance program for people who are older than 65 or have certain disabilities, you can generally expect to pay less in copays than you would pay for private health insurance or other individual plans from the marketplace. Prices vary by plan but your copays, like for a prescription drug, could be less than $5.

Medicaid plans vary by state, so you should check your individual plan to see what the copays are. However, copays with Medicaid are generally much smaller than they are with other plans. For example, in New York, the copay is $3 for visiting a clinic or getting a brand name subscription.

Read more on who qualifies for Medicaid in our state-by-state guide to Medicaid .

Derek Silva

Senior Editor & Personal Finance Expert

Derek is a former senior editor and personal finance expert at Policygenius, where he specialized in financial data, taxes, estate planning, and investing. Previously, he was a staff writer at SmartAsset.

Questions about this page? Email us at  [email protected] .

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What Is a Copay?

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A copay, or copayment, is a fixed fee you pay for a service covered by your health insurance plan . For instance, you may have a copay of $20 for a medical office visit or $10 for a generic prescription drug.

Copay costs vary by plan, and not all plans use copays. Copays are generally lower for using in-network providers and services and higher if you go out of network for care.

How does a copay work?

A copay is a fixed amount you pay each time you get a specific medical service or see a specific provider. It's different from coinsurance , which is when you pay a percentage of the approved charges.

Copay: You pay a flat fee (like $25) every time you see a provider. You pay at the time of service or when you fill a prescription.

Coinsurance: You pay a percentage of the provider’s bill (like 20%), but you don’t pay when you receive services — you’re billed by the provider once insurance approves the charges.

You might have different copays for services such as the following:

Office visit to see your primary care physician.

Office visit to see a specialist.

Urgent care visit.

Emergency room visit.

Generic prescription drug.

Brand-name drug.

Physical therapy visit.

Copay vs. deductible

The annual deductible is the amount you pay toward covered medical services before your insurance starts paying for its share. For instance, if your deductible is $1,500, you’ll have to pay $1,500 out of pocket for covered medical care before your insurance starts covering anything.

You may or may not have to pay copays for services before you reach your deductible. If you pay before hitting the deductible, the amount may count toward the deductible (although it often doesn’t), but it always counts toward your maximum out-of-pocket limit on that health plan. The maximum out-of-pocket limit is the most you’d have to pay in one year for covered medical care.

What is a typical copay?

Copays vary according to the kind of service you receive. You may pay as little as $10 for a visit to your primary care physician and as much as $300 for an emergency room visit.

That said, health plans with copays have fallen in popularity in recent years as more plans use a model with a deductible and coinsurance. Copayments now account for a much smaller percentage of cost sharing than deductibles.

What doesn’t require a copay?

Most health insurance plans are required to cover certain preventive services without a copay or coinsurance. This list includes services such as the following:

Annual checkups.

Blood pressure screening.

Immunizations.

Depression screening.

HIV screening.

Breastfeeding support and counseling.

Cervical cancer screening.

Well-woman visits.

Well-child visits.

Check your own policy to find out which services do and don’t require a copay.

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Does Medicare cover doctor visits?

Medicare Part B is the part of original Medicare that covers the costs of doctor visits. Part C, or Medicare Advantage, also provides this coverage.

Medicare is a federally funded insurance plan consisting of four parts: Part A, Part B, Part C, and Part D . Each part covers different medical expenses.

In 2020, Medicare provided healthcare benefits for more than 61 million older adults and other qualifying individuals.

Today, it primarily covers people who are over the age of 65 years, but younger people with end stage kidney disease and those with certain disabilities are also eligible.

This article explains which parts of Medicare cover doctor visits, what types of appointments they cover, and how much the plans cost.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan: Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments. Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%. Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

What parts of Medicare cover doctor visits?

Original Medicare comprises Part A, which is hospital insurance, and Part B, which covers many medical services, including doctor visits.

Medicare Part B

Medicare Part B covers two types of services: medically necessary and preventive.

Medically necessary services are those that the doctor uses to identify a medical condition when someone presents with symptoms and to provide them with treatment.

Preventive care helps prevent illnesses or stop early stage conditions from progressing. This type of care includes flu shots and screenings, such as cholesterol checks, Pap smears , and mammograms.

Some preventive services have no associated costs when a doctor agrees to accept assignment. This means that the doctor has a contract to bill Medicare directly.

Part B may also pay for other services, such as an ambulance, certain prescription drugs, and durable medical equipment. People can check whether their plan covers the test or service they need using Medicare’s online tool .

Medicare Part C (Medicare Advantage plans)

Medicare Part C plans, also known as Medicare Advantage plans, are an all-in-one alternative to original Medicare that private insurance companies administer. These plans must provide the same coverage level as original Medicare, including coverage for visits to the doctor.

Medicare sends payment directly to the doctor, although individuals may need to pay a coinsurance and meet a deductible. These costs vary by plan.

Medicare resources

For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub .

When does Medicare not cover doctor visits?

Medicare typically does not cover certain services and doctor’s appointments, including :

• podiatry, which can involve callous removal, corn removal, or toenail trimming
• optometry, including regular eye health checkups and getting a new prescription
• naturopathic medicine, including acupuncture — unless it is to treat lower back pain
• dental services, although Medicare Advantage may cover some dentistry
• most chiropractic services , unless they are for spinal subluxation

Part B may limit coverage to a set number of services in a year or lifetime. For example, a person can have blood tests to screen for heart disease once every 5 years .

How much does Medicare pay for a doctor visit?

Everyone with Medicare is entitled to a yearly wellness visit that has no charge and is not subject to a deductible.

Beyond that, Medicare Part B covers 80% of the Medicare-approved cost of medically necessary doctor visits. The individual must pay 20% to the doctor or service provider as coinsurance.

The Part B deductible also applies, which is $203 in 2021. The deductible is the amount of money that a person pays out of pocket before the insurance begins to cover the costs.

A person will also need to pay a premium to keep the policy. The standard monthly premium in 2021 is $148.50.

If a person did not sign up when they were eligible at the age of 65 years, they might also need to pay a late enrollment penalty. This penalty can increase the premiums by 10% for each year that someone qualified for Medicare but did not enroll.

The costs associated with Medicare Advantage Plans vary depending on several factors, including:

• whether the plan has a premium
• whether the plan pays the Medicare Part B premium
• the yearly deductible, copayment, or coinsurance
• the annual limit on out-of-pocket expenses
• the type of healthcare services a person needs

Medicare Part B and Medicare Advantage plans cover visits to the doctor. These plans help people with health insurance plans pay for medically necessary and some preventive care.

Medicare does not limit the number of times a person can see their doctor, but it may limit how often they can have a particular test and access other services.

People can contact Medicare directly on 800-MEDICARE (800-633-4227) to discuss physician coverage in further detail.

A note on insurance

The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products.

Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.

Last medically reviewed on June 25, 2021

• Health Insurance / Medical Insurance
• Medicare / Medicaid / SCHIP
• Primary Care

How we reviewed this article:

• Doctor & other health care provider services. (n.d.). https://www.medicare.gov/coverage/doctor-other-health-care-provider-services
• Items & services not covered under Medicare. (2020). https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Items-Services-Not-Covered-Under-Medicare-Text-Only.pdf
• Medicare Advantage plans. (n.d.). https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans
• Medicare costs at a glance. (n.d.). https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance
• Part B costs. (n.d.). https://www.medicare.gov/your-medicare-costs/part-b-costs
• Part B late enrollment penalty. (n.d.). https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-late-enrollment-penalty
• Total number of Medicare beneficiaries. (n.d.). https://www.kff.org/medicare/state-indicator/total-medicare-beneficiaries/?currentTimeframe=0&selectedDistributions=total&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D,%22states%22:%7B%22all%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
• Your Medicare benefits. (2021). https://www.medicare.gov/Pubs/pdf/10116-Your-Medicare-Benefits.pdf
• What part B covers? (n.d.). https://www.medicare.gov/what-medicare-covers/what-part-b-covers
• What's Medicare? (n.d.). https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare

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Deductibles and Co-pays

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Health care costs have gone up for the sixth year in a row, increasing at rate higher than inflation . Those who can still afford health care are often finding that their benefits are being trimmed while their co-pays and deductibles are increasing. With these growing costs is the growing importance of getting the most out of your health care coverage. Unfortunately, health care policies are often complicated and confusing, filled with jargon that can confuse anyone without a law degree .

A co-payment, or co-pay, is the flat amount you pay at the time of a medical service or to receive a medication . Each health insurance plan establishes these fees up front -- they are often printed on your health insurance card. Insurance companies use these co-pays in part to share expenses with you. In addition to cutting a small portion of the costs, the co-pay is also used to prevent people from seeking care for every trivial medical condition they might encounter.

In this way, co-pays can save an insurance company a substantial amount of money. However, while the co-pay has been found to lower costs by making people think twice before running to the doctor over a case of the sniffles, they might also prevent people from seeking necessary medical attention. For example, a person with a chronic condition may need to see four doctors over the course of a month, all of which require a $25 co-pay. However, if that patient cannot afford $100 each month, he or she will most likely skip one, if not all, of those appointments. Co-pays can often total hundreds of dollars each month if you have several health ailments. In these cases, many patients begin to pick and choose which medications they deem necessary, making for a potentially dangerous situation. But most would say that the alternative -- no health insurance -- would be worse.

Now that we've defined co-pay, let's move on to the deductible. ­

Deductibles

Deductible and co-pay types.

A deductible amount is calculated yearly, so you have to meet a new deductible for each year of the policy. Before you meet this amount, you are required to pay for health care. Once you meet this deductible, however, the health insurance benefits kick in, and you're then responsible only for paying monthly premiums and coinsurance if applicable. Deductible amounts vary by plan and can be separated into individual or family deductibles. In general, a family deductible is double an individual deductible, but it can include several members of a family.

A plan with a high deductible will have a low monthly premium, and vice versa. If you are relatively healthy, a smart rule of thumb when buying a policy is to pick a high deductible to lower your monthly premium costs. If all goes well for your health that year, you won't spend much money on health care expenses, and your monthly premium costs will be very low.

But if something catastrophic occurs, your initial expenses will be high. This is because your entire deductible has to be met before your insurance company will cover many of the services you will likely need, including hospital stays.

A deductible is also considered an out-of-pocket expense and can help you meet your out-of-pocket expense maximum. An out-of-pocket expense maximum, or cap, is the amount you need to meet for the insurance company to pay 100 percent of your health expenses. Normally, your deductible, coinsurance and co-payments can be applied toward this maximum amount. Your monthly insurance premiums are not included in this cap.

Now that both the co-payment and the deductible have been defined, let's find out how they vary with different plans.

Health care services and fees can vary greatly. There are many plans out there, but we'll narrow them down to two main types: fee-for-service plans and managed health care plans.

These types of plans usually have out-of-pocket expense caps. Once you reach the cap, a basic plan will cover doctor's visits and hospital stays, along with all the attendant expenses, like X-rays , medications , treatments and surgery. Major plans pick up where basic plans leave off -- they are usually best for those with yearly medical bills exceeding $250,000.

If you receive health insurance through your employer, it's most likely a managed health care plan. Managed care plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs) and point-of-service plans (POS). A managed health care plan is the best way for insurance providers to control their costs, so they can offer much lower co-pays and deductibles­.

Of the three main types of managed health care plans, HMOs are by far the cheapest and most restrictive. An HMO arranges a provider network by gathering contractual agreements with specialists, general practitioners, hospitals and other health care professionals -- you can receive treatment from this network alone. You have to choose a primary care physician (PCP) who authorizes and coordinates your health care needs by working within the network. As long as you stay within this network, co-payments and deductibles are kept to a bare minimum.

A PPO operates under the same guidelines as an HMO, but it casts a much wider net, and you don't have a PCP acting as an intermediary for your health care. With a PPO, you can choose from within the network of providers for smaller co-pays and deductibles, or pick an out-of-network provider for a substantially higher price.

A POS plan is a fusion of these two managed health care models. It is sometimes referred to as an "open-ended HMO" because you can choose either the HMO or PPO model whenever you need health care. Because of this, your co-pays and deductibles can vary from treatment to treatment, doctor to doctor and month to month.

For more information about co-pays and deductibles, check out the links on the next page.

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More Great Links

• Agency for Healthcare Research and Quality (AHRQ)
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• JAMA: Health Insurance, The Basics. http://jama.ama-assn.org/cgi/content/full/297/10/1154
• AHRQ: Check Up On Health Insurance Choices. http://www.ahrq.gov/consumer/insuranceqa/
• The Seattle Times: "Health-insurance costs up 78 percent in 6 years". http://seattletimes.nwsource.com/html/nationworld/2003880312_ medinsure12.html
• American Heart Association: Managed Health Care Plans. http://www.americanheart.org/presenter.jhtml?identifier=4663
• Insurance Information Institute. http://www.iii.org/media/glossary/

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Pay to enter: Venice becomes the first city to implement a tourist ticket system

Venice became the first city in the world on Thursday to introduce a payment system for visitors in an experiment aimed at dissuading tourists from arriving during peak periods.

However, it isn't the only place in Italy that has recently introduced new measures aimed at slowing tourist flows.

Here are some of the initiatives currently in force.

Venice tourist tax

The lagoon city has introduced 5 euros (about $5.35) tickets for day trippers, valid from 8:30 a.m. to 4 p.m. The experiment came into force on April 25, a national holiday in Italy. Tickets will be needed for the following 10 days and thereafter for most weekends until mid-July.

Venice residents, students, workers, and homeowners are exempt from paying or booking a slot. Visitors aged under 14 and tourists with hotel reservations will need to register, but access for them will be free of charge.

Other cities, such as Como, have said they are considering introducing a similar measure but are waiting to see how the Venice initiative works before deciding.

In addition, Venice has said that from June, it will limit the size of tourist groups to 25 people and ban the use of loudspeakers by tour guides.

Florence tourist measure

Florence announced in October that it was banning new short-term residential lets on platforms such as Airbnb in its historic center. It also offered three years of tax breaks to landlords of short-term holiday lets who start offering ordinary leases for residents.

The city's famous museum, the Uffizi, offers discounts to people who arrive before 8.55 a.m. and lower prices off-season. To spread out crowds, it also closes at 10 p.m. once a week.

Cinque Terrer overtourism

The five villages that make up the Cinque Terre on the Italian Riviera regularly get swamped with visitors.

To try to reduce the overcrowding at peak periods, the authority which oversees the area said this week it would charge visitors 15 euros (about $16) to walk the most celebrated coastal path. In addition, the path can only be walked in one direction.

Capri tourism measure

The picturesque small island that lies across the bay from the southern city of Naples has doubled its entry fee, which is automatically added to ferry tickets, to 5 euros. The fee will be charged from April 1 to October 1.

Capri, Ischia, Procida, Lampedusa and Linosa changes

These islands have introduced limits, or outright bans, on cars for non-residents during the main tourist season.

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Japanese Emperor Naruhito to pay state visit to UK, Buckingham Palace says

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France's foreign minister looks to prevent Israel-Hezbollah conflict escalation in Lebanon visit

France's foreign minister will push proposals to prevent further escalation and a potential war between Israel and Iran-backed Hezbollah during a visit to Lebanon on Sunday as Paris seeks to refine a roadmap that both sides could accept to ease tensions.

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Fact Sheet: Vice President Harris Announces Historic Advancements in Long-Term Care to Support the Care   Economy

Actions are the latest in a series of steps the Biden-Harris Administration has taken to improve safety, provide support for care workers and family caregivers, and to expand access to affordable, high-quality care

Everyone deserves to be treated with dignity and respect and to have access to quality care. That’s why, today, Vice President Harris is announcing two landmark final rules that fulfill the President’s commitment to safety in care, improving access to long-term care and the quality of caregiving jobs. Ensuring that all Americans, including older Americans and people with disabilities, have access to care – including home-based care – that is safe, reliable, and of high quality is an important part of the President’s agenda and a part of the President’s broader commitment to care. Today’s announcements deliver on the President’s promise in the State of the Union to crack down on nursing homes that endanger resident safety as well as his historic Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers , which included the most comprehensive set of executive actions any President has taken to improve care for millions of seniors and people with disabilities while supporting care workers and family caregivers.

Cracking Down on Inadequate Nursing Home Care

Medicare and Medicaid pay billions of dollars per year to ensure that 1.2 million Americans that receive care in nursing homes are cared for, yet too many nursing homes chronically understaff their facilities, leading to sub-standard or unsafe care. When facilities are understaffed, residents may go without basic necessities like baths, trips to the bathroom, and meals – and it is less safe when residents have a medical emergency. Understaffing can also have a disproportionate impact on women and people of color who make up a large proportion of the nursing home workforce because, without sufficient support, these dedicated workers can’t provide the care they know the residents deserve. In his 2022 State of the Union address, President Biden pledged that he would “protect seniors’ lives and life savings by cracking down on nursing homes that commit fraud, endanger patient safety, or prescribe drugs they don’t need.”

The Nursing Home Minimum Staffing Rule finalized today will require all nursing homes that receive federal funding through Medicare and Medicaid to have 3.48 hours per resident per day of total staffing, including a defined number from both registered nurses (0.55 hours per resident per day) and nurse aides (2.45 per resident per day). This means a facility with 100 residents would need at least two or three RNs and at least ten or eleven nurse aides as well as two additional nurse staff (which could be registered nurses, licensed professional nurses, or nurse aides) per shift to meet the minimum staffing standards. Many facilities would need to staff at a higher level based on their residents’ needs. It will also require facilities to have a registered nurse onsite 24 hours a day, seven days a week, to provide skilled nursing care, which will further improve nursing home safety. Adequate staffing is proven to be one of the measures most strongly associated with safety and good care outcomes.

To make sure nursing homes have the time they need to hire necessary staff, the requirements of this rule will be introduced in phases, with longer timeframes for rural communities. Limited, temporary exemptions will be available for both the 24/7 registered nurse requirement and the underlying staffing standards for nursing homes in workforce shortage areas that demonstrate a good faith effort to hire.

Strong transparency measures will ensure nursing home residents and their families are aware when a nursing home is using an exemption.

This rule will not only benefit residents and their families, it will also ensure that workers aren’t stretched too thin by having inadequate staff on site, which is currently a common reason for worker burnout and turnover. Workers who are on the frontlines interacting with residents and understanding their needs will also be given a voice in developing staffing plans for nursing homes. The Biden-Harris Administration also continues to invest in expanding the pipeline of nursing workers and other care workers, who are so essential to our economy, including through funding from the U.S. Department of Health and Human Services.

Improving Access to Home Care and the Quality of Home Care Jobs

Over seven million seniors and people with disabilities, alongside their families, rely on home and community-based services to provide for long-term care needs in their own homes and communities. This critical care is provided by a dedicated home care workforce, made up disproportionately by women of color, that often struggles to make ends meet due to low wages and few benefits. At the same time, home care is still very inaccessible for many Medicaid enrollees, with more than threequarters of home care providers not accepting new clients, leaving hundreds of thousands of older Americans and Americans with disabilities on waiting lists or struggling to afford the care they need.

The “Ensuring Access to Medicaid Services” final rule, finalized today, will help improve access to home care services as well as improve the quality caregiving jobs through its new provisions for home care. Specifically, the rule will ensure adequate compensation for home care workers by requiring that at least 80 percent of Medicaid payments for home care services go to workers’ wages. This policy would also allow states to take into account the unique experiences that small home care providers and providers in rural areas face while ensuring their employees receive their fair share of Medicaid payments and continued training as well as the delivery of quality care. Higher wages will likely reduce turnover, leading to higher quality of care for older adults and people with disabilities across the nation, as studies have shown. States will also be required to be more transparent in how much they pay for home care services and how they set those rates, increasing the accountability for home care providers. Finally, states will have to create a home care rate-setting advisory group made up of beneficiaries, home care workers and other key stakeholders to advise and consult on provider payment rates and direct compensation for direct care workers.

Strong Record on Improving Access to Care and Supporting Caregivers

Today’s new final rules are in addition to an already impressive track record on delivering on the President’s Executive Order on Care. Over the last year, the Biden-Harris Administration has:

• Increased pay for care workers, including by proposing a rule to gradually increase pay for Head Start teachers by about $10,000, to reach parity with the salaries of public preschool teachers.
• Cut child care costs for low-income families by finalizing a rule that will reduce or eliminate copayments for more than 100,000 working families, and lowering the cost of care for lower earning service members, thereby reducing the cost of child care for nearly two-thirds of children receiving care on military bases. Military families earning $45,000 would see a 34% decrease in the amount they pay for child care.
• Supported family caregivers by making it easier for family caregivers to access Medicare beneficiary information and provide more support as they prepare for their loved ones to be discharged from the hospital. The Administration has also expanded access to mental health services for tens of thousands of family caregivers who are helping veterans.

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Pay a visit, pay someone a visit | intermediate english, pay someone a visit.

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Barbados leader halts £3m payout to UK MP for Drax Hall plantation

Government U-turn as PM Mia Mottley acknowledges anger from reparations movement over plan to buy Barbados land from Dorset MP Richard Drax

The prime minister of Barbados, Mia Mottley , has halted plans for a multi-million-pound payout to the British Conservative MP Richard Drax for the purchase of 53 acres of the Drax Hall plantation, which he owns.

As revealed in the Observer last Sunday , the payout plan had angered those involved in the Caribbean reparations movement, who said Drax, the MP for South Dorset, should hand over all or part of the 617-acre plantation to the people of Barbados.

In a seven-minute broadcast to the nation released on YouTube on Tuesday, Mottley explained the government U-turn and said she had decided to pause the purchase to allow further discussion.

She added: “I understand the concern of many Barbadians who may feel they have been robbed of the opportunity of having an appropriate settlement for reparations that ought to be made as a result of the blood, sweat and tears of Barbadians over centuries. This is not a matter we take lightly.”

Trevor Prescod, the MP for St Michael East in Barbados and the lead for reparations on the island, believes his country “should not pay a cent for Drax Hall”. He welcomed Mottley’s announcement but he expressed concern over the word “pause”, saying: “I hope I don’t see a renewal of this commercial relationship with Richard Drax.

“I’ve been getting calls from around the world, and I would like to thank the Observer for bringing this to the attention of people in Barbados, the African diaspora and our friends in England who support reparations. People see the relevance of the damage inflicted on African people. We are the people who were described as chattel slaves. Why should we pay those whose family has enslaved us? The taxpayers of Barbados have risen up to defend their money. The Draxes have had enough from us.”

Drax, who is worth more than £150m, was left the plantation in his late father’s will in 2017. Their ancestors built the sugar plantation in the mid-17th century and worked it with enslaved people for 200 years. After the abolition of slavery in 1834, the family received more than £4,200 in compensation, a huge sum at the time.

The 53-acre site has been selected for the development of 500 lower- and middle-priced houses. Mottley has pledged to build 10,000 homes to meet demand on the island, where there are 20,000 outstanding applications for housing.

A senior valuation surveyor said the market value for agricultural land with an alternative use for housing would be about Bds$150,000 (£60,000) per acre. At this price, the 21 hectares could net Drax £3.2m.

In October 2022 Drax went to Barbados to meet Mottley. It is understood he was asked to hand over all or a substantial part of Drax Hall plantation as reparations.

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In her broadcast, Mottley made it clear she was not happy with the pace at which discussions were proceeding. She said the government was examining its legal options “not only against the owners of Drax plantation, but also all others who have contributed to the conditions of this country being, regrettably, one of the worst examples of modern racism in the Americas”.

Sir Hilary Beckles, who is from Barbados and chairs the Caricom Reparations Commission , a Caribbean-wide body, has described Drax Hall as “a crime scene”, a place where, he estimates, 30,000 Africans died in slavery.

Drax declined to comment. In the past he has said the role his ancestors played in the slave trade was “deeply, deeply, regrettable, but no one can be held responsible today for what happened many hundreds of years ago”.

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Prosecutors at hush money trial say Trump led 'porn star payoff' scheme to 'corrupt' 2016 election

Donald Trump "orchestrated a criminal scheme to corrupt the 2016 presidential election," a prosecutor told jurors Monday during opening statements in the first criminal trial of a former president.

"This case is about a criminal conspiracy and a cover-up,” prosecutor Matthew Colangelo told the 12-person jury and six alternates. Trump, he said, conspired to corrupt the 2016 presidential election by scheming with his lawyer Michael Cohen and David Pecker, who was the publisher of the National Enquirer at the time.

“Then, he covered up that criminal conspiracy by lying in his New York business records over and over and over again,” Colangelo said.

Pecker was called as the prosecution's first witness following opening statements from both sides. Trump's lawyer Todd Blanche told the jury his client was not guilty because no crime was committed.

Trump, who had his eyes closed for periods during the morning proceedings, seemed much more engaged when his old ally and friend Pecker was taking the stand. Trump craned his neck when Pecker walked in, almost as if to see whether Pecker would meet his eye. Trump also poked at his attorney Emil Bove and whispered something as Pecker, 72, got situated, and he leaned forward attentively when he began testifying.

Pecker did not get to his relationship with Trump by the time the court day ended. The proceedings ended early because a juror had an emergency dental appointment.

Trump told reporters afterward that the case was "unfair" and launched into an attack against Cohen, who's expected to be called as witness.

"When are they going to look at all the lies that Cohen did in the last trial? He got caught lying in the last trial. Pure lying," Trump said, apparently referring to Cohen's statement in the civil fraud case against Trump that he lied under oath during part of his 2018 guilty plea. "When are they going to look at that?” Trump said.

The comments are likely to come up at a hearing Tuesday morning, when Manhattan District Attorney Alvin Bragg's office is scheduled to argue that Trump has repeatedly violated a partial gag order barring him from making "public statements about known or reasonably foreseeable witnesses concerning their potential participation in the investigation or in this criminal proceeding."

Prosecutors have said Cohen and Pecker, the longtime former publisher of the Enquirer, are central figures in the alleged scheme to bury claims from women who said they had had affairs with Trump.

Colangelo told the jurors they will hear about a 2015 meeting at Trump Tower with Trump, Cohen and Pecker. Both Cohen and Pecker had specific roles to play in the scheme, Colangelo said. “Cohen’s job really was to take care of problems for the defendant,” he said. “He was Trump’s fixer.” Pecker, meanwhile, would act as “the eyes and ears” for Trump and would let him and Cohen know about any allegations that could hurt his campaign.

The DA alleges the three conspired to hide “damaging information from the voting public.” That included allegations from a former Playboy model named Karen McDougal who said she had a 10-month sexual relationship with Trump that ended in April 2007. Pecker’s AMI agreed to pay her $150,000 in a deal to essentially buy her silence — a practice that was referred to as “catch and kill.” Trump has denied McDougal's claims.

The situation took on a greater sense of urgency for Trump in October 2016. That's when The Washington Post published the " Access Hollywood " tape, which caught Trump on a hot mic saying he could grope women without their consent because "when you're a star, they let you do it."

Judge Juan Merchan barred the DA from playing the tape for the jury for fear it would be too prejudicial, but he did allow prosecutors to use a transcript of Trump's remarks.

Colangelo said the impact of the tape was “immediate and explosive.”

“The defendant and his campaign were concerned that it would irrevocably damage him with female voters,” he said, and "the campaign went into immediate damage control mode."

It was around that time that the Enquirer heard that adult film actress Stormy Daniels was interested in coming forward with a claim that she had a sexual encounter with Trump in 2006. Trump was "adamant" he didn't want that claim, which he denies, to become public for fear it would be "devastating" to his campaign, Colangelo said.

Cohen then struck a deal to buy Daniels' silence for $130,000, Colangelo said.

"It was election fraud, pure and simple," Colangelo said, adding “We’ll never know, and it doesn’t matter, if this conspiracy was a difference maker in the close election.”

Colangelo said the Trump Organization, Trump’s company, couldn’t cut Cohen a check with the memo “reimbursement for porn star payoff” so "they agreed to cook the books" and make it look like the reimbursement was income.

"The defendant said in his business records that he was paying Cohen for legal services pursuant to a retainer agreement. But, those were lies. There was no retainer agreement," Colangelo said.

“It was instead what they thought was a clever way to pay Cohen back without being too obvious about it,” he said. But what they did was a crime, Colangelo said. “Donald Trump is guilty of 34 counts of falsifying business records in the first degree,” he concluded.

Trump's attorney Blanche countered in his opening statement that his client hasn’t committed any crimes. “The story you just heard, you will learn, is not true,” he said. "President Trump is innocent. President Trump did not commit any crimes."

He said the only thing Trump did was sign checks for legal services rendered by his lawyer.

“The invoice is processed, somebody at Trump Tower generated a check, the check was ultimately signed, and there was a record in the ledger,” Blanche said. “He’s the only signatory on his personal checking account, which is why he signed the check.

"So what on Earth is a crime? What’s a crime, of what I just described?” Blanche said. "None of this is a crime," he said, adding that nondisclosure agreements like the one Daniels signed are legal.

As for the election interference argument, Blanche said, “I have a spoiler alert: There’s nothing wrong with trying to influence an election. It’s called democracy.”

In a preview of his trial strategy, Blanche also attacked Daniels' and Cohen's character and credibility. He accused Daniels, whom he described as "extremely biased," of trying to "extort" Trump, a word that the judge ordered stricken from the record. Blanche then said what Daniels had been threatening to do by going public with her allegation was "sinister" and "damaging to [Trump] and damaging to his family.”

Blanche also said Daniels' testimony, while salacious, doesn't matter because she doesn't know anything about how Cohen was repaid.

The bulk of Blanche's attacks were reserved for Cohen, who pleaded guilty in 2018 to numerous crimes, including some that he said he carried out on Trump's behalf.

“Michael Cohen was obsessed with President Trump. He’s obsessed with President Trump, even to this day,” Blanche said, calling him a "convicted felon" and a "convicted liar."

“He has talked extensively about his desire to see President Trump go to prison,” Blanche said, including in public on Sunday.

He told the jurors that if they listen to the evidence, they'll return "a very swift not guilty verdict."

Cohen said in a statement afterward, “The facts will come out at the time of trial that contradicts Todd Blanche’s mischaracterizations of me.”

Trump faces 34 counts of falsifying business records related to the hush money payment to Daniels. Trump, who has pleaded not guilty , could face up to four years in prison if he is convicted.

On his way into the courtroom Monday morning, he told reporters: “It’s a very, very sad day in America. I can tell you that.”

The day got off to a rough start for Trump, with Merchan, the judge, ruling that if he winds up taking the stand in his own defense, prosecutors can cross-examine him about another New York judge's finding that he and his business committed "persistent" fraud and violated a gag order, juries' finding him civilly responsible for sexual abuse and defamation in the E. Jean Carroll cases and a settlement in a case that found he used his now- shuttered foundation to improperly further his campaign in the 2016 election. Trump's attorneys had argued that all of those topics should be out of bounds.

Trump didn't show concern — he sat with his eyes closed through much of Merchan's ruling. He briefly opened his eyes when the jury was brought in for the judge's instructions and then closed them again.

Bragg was sitting in the front row of the courtroom ahead of opening statements.

Cohen, Daniels and McDougal are also expected to testify during the trial, which is estimated to take six weeks.

The jury consists of seven men and five women. The final day of jury selection, Friday, was particularly intense , as some potential jurors broke down in tears and said they were too anxious to be seated. They were excused. A man also set himself on fire outside the courthouse.

Trial proceedings Tuesday will be abbreviated, ending at 2 p.m. ET because of the Passover holiday.

Adam Reiss is a reporter and producer for NBC and MSNBC.

Dareh Gregorian is a politics reporter for NBC News.

Jonathan Allen is a senior national politics reporter for NBC News, based in Washington.