Dealing with Co-Pays, Co-insurance, Large Out-of-Pocket Amounts and the All-Comers Issue

Co-pays and co-insurance are tools that are meant to make people think about the necessity of getting care.

Co-pays are asked when it is desired to speed things up and co-insurance when just cost reduction is wanted.

If people really need care, drugs and devices, imaging and testing then they should be willing to pay something.

Wanting things and services for “free” is a sort of mental illness that itself needs fixing.


To ask an adult to pay a $10 co-pay for a doctor visit worth $100 isn’t too much.

It takes about 90 minutes or less of work at a local McDonalds’s to earn $10 after tax.

Insurers should be able to ask $20 co-pays for specialist office visits.


To ask an adult, capable of doing work paying $7.25 or more per hour to pay $100 or 20% co-insurance for a CAT/MRI scan isn’t too much. On a scan costing $600, 20% is $120.

That $120 can be paid using the proceeds of 3 eight-hour days of paid work or less. Most adults not on Medicare work over 200 days a year.


Drugs that should be cheap should be cheap, insurance shouldn’t change that.

Drugs should be subject to market forces insomuch as possible.

Drug cost co-pays and co-insurance that can’t be paid from household income should be subject to help from the drug maker, charitable organizations, one’s family, relatives and friends. State governments could also help out.

In some cases where less than 10,000 people have been treated annually, the federal government should seek to buy a national supply on an all the doctors prescribe basis at an expertly determined reasonable price, with annual Congressional grants, with Congressionally set co-pays by drug, corresponding with expertly estimated unit marginal manufacturing cost.


Tests are normally relatively inexpensive. A small percentage of a modest sum is a very modest sum.

Some tests are expensive, but those generally only have to be done once or a few times in one’s life.

Nuclear medicine tests are inherently expensive. Some detect when cancer reoccurs.

The insurer should only have to cover federal law listed nuclear medicine tests at an insurer co-pay of no more than $600 or 10% to 20% co-insurance for each test at the two lowest bidding providers and at such others the i it might choose to include in its network:

  1. within the state of issue or an adjacent state or state less than 400 miles away from the state of issue
  2. at an insurer contracted center in an area one flight away from the largest metropolitan area in the state of issue.


  1. federal health coverage law listed patent-free nuclear medicine tests
  2. federal health coverage law listed price-regulated nuclear medicine tests for which all related patent holders have requested federal law price caps in writing to the Commissioner of the FDA and those writings have been published in the Federal Register

High-volume, lower cost nuclear medicine test centers could be set up at or by major airports such as JFK, O’Hare, Atlanta, LAX, DFW, BWI, Orlando, etc. by private sector entities.

People generally have several months to gather up a nuclear medicine test co-pay.


Admit co-pays shall be policy listed, but no more than:

  1. $300 for EMTALA level urgent and birthing cases
  2. $2,500 for joint replacement, back or bariatric surgery, not reduced by the insurer
  3. $3,000 for a procedure not approved by CMS (Medicare) and not pre-approved by the insurer
  4. $1,500 if not pre-approved by the insurer with an approval code being given to the insured/policy holder/institution
  5. $500 for an insured who is getting or whose household gets federal phone help or is federal phone help eligible, except as above
  6. $1,000 otherwise

Insurance shall fully cover any federal phone help co-pay differential.

Insurance companies may individually lower the joint replacement, back or bariatric surgery co-pay after receiving an evidence-backed request of a treating physician.

The daily stay co-pay shall not exceed $80/day for federal phone help (household) (eligible) insureds and $150/day otherwise, with insurance fully covering the institution for the difference.

There shall be no admit co-pay for newborn congenital condition surgery cases.

It shall be a felony to possess anesthetic agents or FDA regulated drugs on the grounds or property of or inside any hospital or comparable institution/complex that for EMTALA scope care that willfully charges a patient anything except:

  1. an EMTALA level admit co-pay with a cap of $300 or less after December 31, 2017, with respect to all patients having federally regulated health coverage/insurance obtained after December 31, 2015 and/or
  2. an ER co-pay with a cap of $100 or less after December 31, 2017, with respect to all patients having federally regulated health coverage/insurance obtained after December 31, 2015.

[That’s to ensure hospitals impose and stick to those co-pay caps.]

For EMTALA scope care, insurers would have to pay to out-of-network hospitals, the higher of:

  1. what the insurer pays an in-network hospital in the same or an economically comparable community in the same state of comparable physical size or number of employees, whose name shall be furnished to the out-of-network hospital with the insurer’s payment(s), plus a somewhat or totally random additional amount between 3% to 10%
  2. what Medicare would pay to the out-of-network hospital plus 20% as of the first date of care
  3. what Medicare would have paid to the out-of-network hospital plus 20% as of January 2013, adjusted for inflation using the latest federal CPI and that for January 2013


The amounts due from an insured patient shall:

  1. not exceed the Medicare Part B amounts for all Medicare approved type surgery, in an in-network facility or
  2. be the provider set amount (but not more than $1,000) for surgery not approved by Medicare, but approved by the insurer, in an in-network facility

For out-of-network, non-hospital provider, the insurer shall pay the amount Medicare would pay to the provider for the insured, once:

  1. the provider has informed the responsible party/parties and the insurer by certified mail that total amount due from the responsible parties/parties is no more than twice the Medicare Part B co-insurance/co-pay amount

Within thirty days after receipt of the insurer’s payment, the out-of-network, non-hospital provider shall refund/reimburse any payments, except (to reimburse for) court costs, in excess of these amounts ASAP.

For surgical/procedural care after December 31, 2015, except dental care, that is not Medicare or insurer approved, every payment shall be refunded that is not specifically asked for in full in dollars (and cents) prior to work in writing or paid in full in advance.


A person may obtain mandatory issue coverage, by paying premiums adjusted above the base amount by insurer set percentages up to the following percentages:

  1. 2% for each whole month the person has been without health insurance in the last 22 months as of the date of application, excluding up to two months in a calendar year
  2. 10% for each hospital admission, up to three, for the person in the last three calendar years as of the date of application/renewal
  3. 10% if an ER has been used in the last 90 days by the person as of the date of application
  4. 10% for each calendar year an application listed orphan/recombinant/patented/exclusive drug that has cost the insurer more than $4,000/year has been used in the last 22 months as of the date of application/renewal
  5. 20% if the person has had chemotherapy for cancer in the last 22 months as of the date of application
  6. 10% if the person has used US government taxable tobacco products in the last 60 days as of the date of application

An insurer may take legal action to recover premium money that should have been paid plus court costs plus 30% (or less, if limited by state law) for attorney fees.

An insurer shall not drop coverage unless the amount owed it increases by over the amount of two proper premiums per policy.


States may seek federal help on large out-of-pocket spends on medically necessary medical care and any percentage from 10% to 100% of exchange/Medicare/Medicaid premiums paid for any month or months, which may vary by household income, as its legislature sees fit by statutory law in excess of:

  1. any state’s Medicaid monthly spenddown expectation defined by or referred to by the law of the state or
  2. any state defined percentage(s) of household income for state defined period(s), which may vary by household income

with all exclusions set by state statutory law, and never more than the actual out-of-pocket amount spent.

The state may reclaim from the federal government the help given by the state’s out-of-pocket help program except on:

  1. out-of-pockets on what is/are or could be cosmetic surgery, sex change treatment, or abortions, except in cases needed to save the life of mother, or of rape or incest for which the victim has filed a police report (if legally competent to stand trial for perjury or the sale of a controlled substance) and fetal DNA material has been properly provided to law enforcement under a chain of custody system
  2. out-of-network co-pay and out-of-network co-insurance amounts
  3. amounts that are or could be for chiropractic care, care that is thought dubious by regulation or a federally employed doctor or nurse, or for dental care in a hospital
  4. 50% of state help amounts for dental care outside of a hospital

less all of the following (on the amount of state out-of-pocket help, excluding all of the above):

  1. 30%
  2. the state’s highest personal income tax percentage
  3. 50% of the state’s general sales tax rate percentage
  4. 4% if the state levies a broad sales tax or like on services

The reductions for income tax and general sales and service taxation are to ensure the state is actually at least 30% poorer for giving out-of-pocket help and doesn’t get a free windfall of federal funds indirectly through in-state, unregulated, greedy providers.

To prevent generous states from getting inundated with moochers from el cheapo states, a state may alternately by law provide any out-of-state level of help for any person to be helped who has spent most of their life out-of-state in the last five years.