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, so the correct statement is the one that makes the member owe the $30 copay OR 20% coinsurance ($100) per the plan's design, unless the schedule explicitly stacks them. The response charging the $250 deductible again wrongly assumes the deductible reapplies (the prompt said it was met). The response charging the member 100% of the $500 ignores the plan's coverage entirely. And the response paying only the $30 copay no matter what the schedule says assumes copay-only without checking the plan's design.