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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.

Not everyone in Vital has copays. Your ID card will tell you if you have copays and what they are. Copays depend on the type of Vital you have. Your ID card says what type of Vital you have.

None of your doctors or providers can refuse to give you medically necessary services because you don’t pay your copays. However, your Insurer 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.

COPAY CHARTS

 
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 ID card or call us at 1-800-981-1352.
 

CO-PAYS & Co-INSURANCE – effective on July 1st 2016
SERVICES Federal CHIPs Conmmonwealth *ELA
100 110 120 130 220 230 300 310 320 330 400
HOSPITAL
Admissions $0 $4 $5 $8 $0 $0 $15 $15 $15 $20 $50
Nursery $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
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
AMBULATORY VISITS TO
Primary Care Physician (PCP) $0 $1 $1.50 $2 $0 $0 $2 $2 $5 $5 $3
Specialist $0 $1 $1.50 $2 $0 $0 $2 $2 $5 $5 $7
Sub-Specialist $0 $1 $1.50 $2 $0 $0 $2 $2 $5 $5 $10
Pre-natal services $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
OTHER SERVICES
High-Tech Laboratories** $0 50¢ $1 $1.50 $0 $0 $2 $2 $5 $5 20%
Clinical Laboratories** $0 50¢ $1 $1.50 $0 $0 $2 $2 $5 $5 20%
X-Rays** $0 50¢ $1 $1.50 $0 $0 $2 $2 $5 $5 20%
Special Diagnostic Test** $0 $1 $1.50 $2 $0 $0 $2 $2 $5 $6 40%
Therapy – Physical $0 $1 $1.50 $2 $0 $0 $2 $2 $5 $5 $5
Therapy – Respiratory $0 $1 $1.50 $2 $0 $0 $2 $2 $5 $5 $5
Therapy – Occupational $0 $1 $1.50 $2 $0 $0 $2 $2 $5 $5 $5
Vaccines $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
Healthy Child Care $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
DENTAL
Preventive (Child) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
Preventive (Adult) $0 $1 $1.50 $2 $0 $0 $2 $2 $3 $5 $3
Restorative $0 $1 $1.50 $2 $0 $0 $2 $2 $5 $6 $10
PHARMACY***
Preferred (Children 0-21) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $5
Preferred (Adult)**** $0 $1 $2 $3 N/A N/A $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 N/A N/A $8 $8 $10 $10 $10

* 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.

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