How Much to Charge the Member

Deductibles

• HMSA’s HMO commercial plans do not include deductibles. For HMO commercial members you need only charge the applicable copayment.
• However, many of HMSA’s PPO plans have deductibles.

If the member’s annual deductible has not been met or has only partially been met, please estimate the amount of the items eligible charge that will be applied to the deductible. If it is estimated that all of the eligible charge will be applied to the deductible, you may charge the member in full for the item. If you estimate incorrectly, and HMSA makes a payment for the item, you should refund the member accordingly.

If the member’s annual deductible has already been met for the year, or if the service is not subject to a deductible (e.g., most immunizations) do not charge the member in full at the time of service. However, you may charge the member for any applicable copayment.

Copayments

A pharmacy can decide how much to charge the member at the time of service in one of two ways:

• Estimate how much the patient owes and charge the appropriate copayment based on the estimate. When the Report to Provider (RTP) is received showing how much the member owes, either refund the member if you overestimated the copayment amount, or bill the member if you underestimated.

The pharmacy might also choose not to ask for a copayment at the time of service, and to bill the member for any copayment he or she may owe after the RTP is received and posted.

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