Responsibility for Costs in an MSA

MSAs have a simpler cost sharing model than most other plan types.

No Premiums, Copays or Coinsurance

Health insurance plans typically have multiple payment components that, together, form your benefit. These are some of the common components:

Premium

A premium is a payment, usually monthly, a member makes to the insurance company to be covered under the plan. A member pays it each month, even if they don’t use benefits in that month, otherwise they could lose their coverage.

A copay is a predetermined rate a member pays for certain health care services. The member pays these directly to the provider when receiving the care. Some examples are a $20 primary care office visit, a $10 prescription fill, a $50 specialist visit and a $100 emergency room visit.

A deductible is how much a member pays for covered services before the insurance company starts paying (or starts paying at a higher percentage). It is an annual amount and resets each benefit year.

Coinsurance is an amount a member pays for covered services, typically after they’ve met their plan deductible. It’s usually expressed as a percentage. For example, a 25% coinsurance means that for additional covered services a member incurs beyond their deductible, they pay 25% of the costs and the insurance company pays 75%.

The out-of-pocket maximum is the upper limit of what a member pays for their covered health services before the insurance company covers 100%. It’s an annual amount and resets each benefit year.

In an MSA, the deductible is technically the out-of-pocket maximum. It’s the most a member pays for covered services before we start paying.

Our plan deductibles are higher than the deposit amounts, so members will most likely pay some costs from their own funds. We call that the “covered expenses out-of-pocket” or “equivalent out-of-pocket.” The provided deposit is intended to be applied to the deductible amount, which lowers the amount of personal funds needed to reach the deductible.

Fenyx Health’s Group MSA plans simplify the cost sharing arrangement, as there are NO premiums, copays or coinsurance.

Members Pay 100% of Covered Costs Below the Deductible. We Pay 100% Above the Deductible

Now, that is pretty easy.

Type of ExpenseWho Pays Under the DeductibleWho Pays Above the Deductible
Medicare A/B Costs by Medicare-participating ProvidersMemberFenyx Health
Medicare A/B Costs by Non-Medicare ProvidersMemberMember
Other Medical CostsMemberMember
Non-medical CostsMemberMember

Our special financing program helps members manage, pay for and save on plan-covered costs under the deductible.

Some Costs Are Always The Member’s Responsibility to Pay

Like any insurance plan, there are some costs that are not covered under the MSA. The items below do not count toward the MSA deductible and are always a member’s responsibility to pay:

  • Expenses that are not Medicare A/B-covered items and services
  • Medicare A/B items and services provided by providers who have opted out of Medicare
  • Any excess charges from providers not participating in Medicare but accepting of Medicare rates. Some states allow these providers to bill extra charges up to a set maximum amount (a practice called “balance billing”).

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