WILL I HAVE TO PAY TO GET HEALTH CARE SERVICES?
Sometimes you will have to pay to get health care services. Preventive care is care that helps you stay well, like checkups, shots, pregnancy care, and childbirth. This kind of care is always free. You don’t have copays for preventive care.
For other care like hospital stays or sick child visits, you may have to pay part of the cost. Copays are what you pay for each health care service you get.
Sometimes you will have to pay to get health care services. Preventive care is care that helps you stay well, like checkups, shots, pregnancy care, and childbirth. This kind of care is always free. You don’t have copays for preventive care.
For other care like, hospital stays or sick child visits, you may have to pay part of the cost. Copays are what you pay for each health care service you get.
Not everyone in Plan Vital has copays. Your Plan Vital membership card will indicate if you have copays and what they are. Copays depend on the type of coverage you qualified under Plan Vital. Your Plan Vital member card indicates what type of coverage you have.
None of your doctors or providers can refuse to give you medically necessary services because you don’t pay your copays. However, Triple-S Salud and your providers can take steps to collect any copays you owe.
You should only have to pay your copay for your care. You should not be billed for the rest of the cost of your care. If you are billed for the rest of the cost, you can appeal. Look at section Complaints and Appeals for more information.
COPAYS
Do you have to pay copays for a PCP, Specialist, ER visit, hospital stay, or other type of service? Not sure? Check the chart below, look at your Member card or call Triple-S Salud at 1-800-981-1352, TTY/TDD users should cal 1-8855-295-4040.
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BENEFIT PACKAGES, CO-PAYS & CO-INSURANCE – Effective on January 2023 |
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| BENEFIT PACKAGES &SERVICES FOR MENTAL HEALTH (MH), SUBSTANCE USE DISORDER (SUD), MEDICAL/SURGICAL (M/S) | FEDERAL | CHIPs | Commonwealth | *ELA | |||||||
| 100 | 110 | 120 | 130 | 220 | 230 | 300 | 310 | 320 | 330 | 400 | |
| HOSPITALIZATION SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $15 | $15 | $15 | $20 | $50 |
| Admissions | $0 | $0 | $0 | $0 | $0 | $0 | $15 | $15 | $15 | $20 | $50 |
| Nursery | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Behavioral health hospitalizations | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Detoxification Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Inpatient behavioral Health Services in an Institution for Mental Disease (IMD) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| BEHAVIORAL HEALTH SERVICES | |||||||||||
| Evaluation, screening, and treatment of individual, couples, families, and groups |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Outpatient services with psychiatrist, psychologist, and social workers |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Hospital services for substances and alcohol abuse disorders |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Outpatient services for substance and alcohol abuse disorders | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Intensive outpatient services |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Emergency or crisis intervention services |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Long-lasting injected medicine clinics | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Escort/professional assistance and ambulance services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Prevention and secondary- education services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Treatment of attention deficit disorder | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Substance abuse treatment | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Opiate addiction treatment | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Partial hospitalization | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Electroconvulsive Therapy (EC) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Psychological / Neuropsychological testing | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| PREVENTIVE HEALTH SERVICES | |||||||||||
| Well baby care | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Immunizations | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Hearing Exams | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Evaluation and nutritional screening |
$0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Laboratory and Clinical Tests |
$0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $6 | 20% |
| Nutritional, oral and physical health education | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Reproductive health/family planning | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Annual physical exam for diabetics | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Health certificates | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Diagnostic Test Services | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $6 | 40% |
| OUTPATIENT REHABILITATION SERVICES | |||||||||||
| Physical therapy | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $5 |
| Occupational therapy | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $5 |
| Speech therapy | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $5 |
| EMERGENCY ROOM (ER) | |||||||||||
| Emergency Room (ER) Visit | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $10 | $15 | $20 | $20 |
| Non-Emergency Services Provided in a Hospital Emergency Room, (per visit) |
$0 | $4 | $5 | $8 | $0 | $0 | $20 | $20 | $25 | $30 | $20 |
| Non-Emergency Services Provided in a Freestanding Emergency Room, (per visit) |
$0 | $2 | $3 | $4 | $0 | $0 | $20 | $20 | $25 | $30 | $20 |
| Trauma | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| MEDICAL AND SURGICAL SERVICES | |||||||||||
| EPSDT / early and periodic screening, diag, treat<21 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Primary care physician’s visits including nursing services | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $3 |
| Specialist treatment | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $7 |
| Sub-specialist treatment | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $10 |
| Physician home visits | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $10 |
| Respiratory therapy | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $5 |
| Anesthesia services (except of epidural) | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | $5 |
| Radiology services | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Pathology services | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Surgery | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Outpatient surgery facility services | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Nursing services | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Sterilization | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Prosthetics | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Ostomy equipment | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Blood transfusion and blood plasma services | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Services to patients with Level 1 or Level 2 chronic renal disease | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Skin, bone, and corneal transplants | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Veklury (remdesivir) for COVID-19 | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Breast reconstruction after mastectomy | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Surgical procedures to treat morbid obesity | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Mechanical respirators and ventilators | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| *Durable Medical Equipment | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Emergency Transportation Services | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Maternity and Pre-natal services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Other Services | |||||||||||
| High-Tech Laboratories** | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $5 | 20% |
| Special Diagnostic Tests** | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $6 | 40% |
| Dental Services | |||||||||||
| Preventive (Child) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Preventive (Adult) | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $3 | $5 | $3 |
| Restorative | $0 | $0 | $0 | $0 | $0 | $0 | $2 | $2 | $5 | $6 | $10 |
| Pharmacy Services | |||||||||||
| Preferred (Children 0-21) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $5 |
| Preferred (Adult)**** | $0 | $1 | $2 | $3 | $0 | $0 | $3 | $3 | $5 | $5 | $5 |
| Non-Preferred (Children 0-21) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $10 |
| Non-Preferred (Adult)**** | $0 | $3 | $4 | $6 | $0 | $0 | $8 | $8 | $10 | $10 | $10 |
* All Durable Medical Equipment (DME) is not covered; however, DME may be covered on a case-by-case basis under an exceptions process.
** Copays apply to diagnostic tests only. Copays do not apply to tests required as part of a preventive service.
*** Copays apply to each medicine included in the same prescription pad.