Do you ever look at your health insurance plan and notice a term that says out-of-pocket costs or cost sharing? Are you confused to what that actually means? Here at Central Florida Pediatric Urgent Care, we are here to clear up the air and sort out any confusion you may have. Located in the heart of Orlando, we are health team that is dedicated to providing the best healthcare and experience to your child. We are after-hours pediatrics office that cares.


What is this?

Basically, this is the costs of the health care that is covered by you. Hence the term out-of-pocket. This is the amount you are literally paying for with money in your pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges. However, it does not cover premiums, balance billing amounts for non-network providers, or the cost of non-covered services. What is the break down of the fees and situations when it comes to after-hours pediatrics?


What Are Some Types of Cost Sharing Arrangements and Situations


  • Coinsurance
    • For this, you pay a fixed percentage of each service. For example, let’s say your coinsurance is 25%. You would need to pay 25% of the $65 allowable to the doctor (.25 x $65 = $16.25). Your insurance company will pay for the rest ($65 – $16.25 = $48.75).


  • Copay
    • This a fixed amount you pay per service. For instance, if your copay is $25 and you are expected to pay $25 and your insurance will pay the remaining $45 ($25 + $45 = $65). You may need to pay a copay for emergency services. Be sure to check the plan you are enlisted in and look into the details for emergency services.


  • Deductible
    • When it comes to a deductible, you need to pay the entire amount that is provided by the insurance company before insurance covers any balance of healthcare. This amount typically does not cover copays. If your insurance plan has a $950 deductible, the out-of-pocket maximum refers to your cost-sharing agreement after your deductible has been met. Keep in mind the deductible starts over every year.


  • Out-of-Pocket Maximum
    • This is the most amount of money that you are expected to pay in cost-sharing with a plan year. The limit will never exceed this amount. Unlike your deductible, the out-of-pocket maximum refers to your cost-sharing arrangement after your deductible has been met. For example, if an insurance plan has a deductible of $950 and a $1,300 out-of-pocket maximum, coupled with 25% coinsurance. In this case, you would pay the entire $65 for the doctor’s visits under your deductible. Having met your deductible, you would then pay $16.25 per office visit (because your 25% coinsurance) until you spend the correct amount in coinsurance. At that point, you would pay nothing more for medical care for the remainder of the plan year.


Contact Us Today

Dealing with cost sharing and insurance can get very complicated and confusing. Do not stress out. Simply call Central Florida Pediatric Urgent Care today, and we will be happy to explain the process further for you. We are an after-hours pediatrics office which is based in Orlando. Contact us today!