A health plan member sees an in-network specialist for a service that costs $500. The plan has a $250 deductible (already met), 20% coinsurance, and a $30 copay for specialist visits. After meeting the deductible, the typical structure is:
Explanation
Cost-sharing terms in California are defined under Insurance Code §10123 and managed-care regulations. A 'deductible' is the amount the member pays before the plan starts paying. A 'copay' is a fixed dollar amount per service. 'Coinsurance' is a percentage of the cost the member pays after the deductible. Most plan designs apply EITHER a copay OR coinsurance for a given visit — not both — and the Summary of Benefits & Coverage spells out which. Option A wrongly assumes the deductible reapplies (the prompt said it was met). Option B ignores the plan's coverage entirely. Option C assumes copay-only without checking the plan's design. Option D correctly captures that the answer depends on what the plan's schedule specifies.
Law Reference: Cal. Ins. Code §10123 (cost-sharing definitions)Practice all 315 questions free — no signup required.
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