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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2016 State of Wisconsin Group Health Insurance Program
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Wisconsin Department Of Employee Trust Funds It's Your Choice 2016


Local Health Plan
Insurance for Employees
and Retirees
(PO6)


Guide to Office Visit Copayments

Beginning in 2016, you may have to pay copayments when you visit your doctor. Copayments are different from coinsurance in a few ways:

Copayments

  • You are typically required to pay your copayment to your doctor’s office at the time of your visit
  • Copayments are a set dollar amount (e.g. $15 per visit)
  • Deductible may not apply, depending on your health plan design

Coinsurance

  • Doctor’s office/clinic mails you a bill after your visit
  • Coinsurance is a percentage of the amount owed to the doctor/clinic (e.g. 10%)
  • Deductibles must be paid before coinsurance applies

You will not have to pay copayments for preventive care office visits. Copayments are for the office visit only, and do not cover any additional services you might receive during your visit (e.g. lab work or x-rays). Any additional services are subject to your deductible and coinsurance. Examples of services and the applicable copayments are listed in the chart below.

Office Visit Type

$15 Primary Care Visit

$25 Specialty Visit

Family Practice

 

General Practice

 

Internal Medicine

 

Gynecology/OB

 

Midwives

 

Nurse Practitioners

 

Physician Assistant

 

Pediatrics

 

Urgent Care

 

Chiropractic

 

Home Health Visit

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Palliative Care Visit


For PCP Only


For Specialist Only

Vision Exam

 

Pre/Postnatal Visits

•**
For family practice with obstetrics or OB/GYN

•**
For maternal/fetal specialist 

Mental Health Visits/Therapy

 

Physical Therapy

 

Occupational Therapy

 

Speech Therapy

 

Other Practitioner

 

** If all prenatal visits are billed as a package at the end of pregnancy, then deductible and 10% coinsurance apply. Check with your doctor’s office for more information.

Disclaimer:
Every effort has been made to ensure that this information is accurate, but may be subject to change. Please note revision dates located at the bottom of each page. In the event of conflicting information, federal law, state statute, state health contracts and/or policies and provisions established by the State of Wisconsin Group Insurance Board shall be followed.

This page was last modified on: 11/16/2015 4:56:27 PM