Your insurance benefits are what your insurance pays for and what you pay yourself. Your insurance sets them, and they can change each plan year. Check them before you book, so the cost of your appointment is not a surprise.
Looking for something else?
Whether Circle Medical works with your insurance: What insurance plans is Circle Medical in-network with?
Medicare: Does Circle Medical accept Medicare?
Medicaid: Does Circle Medical accept Medicaid?
What a self-pay appointment costs: Appointment costs
A charge, an explanation of benefits (EOB), or a denied claim after your appointment: After your appointment: claims, EOBs, and charges
A prior authorization for a medication, test, or referral: How prior authorizations work at Circle Medical
What do the terms on my insurance mean?
You'll see these terms on your insurance card, in your insurance's app, and on your summary of benefits.
Term | What it means |
Covered | Your insurance pays for some or all of a service. A service your insurance does not pay for is non-covered. |
In-network | Your insurance has an agreed rate with the provider. In-network appointments usually cost you less. |
Allowed amount | The most your insurance pays for a service. Your deductible, copay, and coinsurance are based on this amount. |
Deductible | The amount you pay each plan year before your insurance starts to pay more. With a $2,000 deductible, you pay the first $2,000 of covered care. |
Copay | A set amount you pay for an appointment or a prescription, for example $20. |
Coinsurance | A share of the cost you pay after you meet your deductible. With 20% coinsurance, you pay 20% and your insurance pays 80%. |
Out-of-pocket maximum | The most you pay for covered care in a plan year. After you reach it, your insurance pays the full allowed amount for covered care. |
Plan year | The 12 months your benefits cover. Many deductibles start again at the beginning of each plan year. |
Summary of benefits | A document from your insurance that lists your deductible, copays, coinsurance, and out-of-pocket maximum. |
Pharmacy benefits | The part of your insurance that covers prescriptions. A separate company called a pharmacy benefit manager (PBM) often runs it, such as CVS Caremark, Express Scripts, or OptumRx. |
How do these work together?
Until you meet your deductible, you usually pay the allowed amount yourself.
After that, you pay a copay or coinsurance.
After you reach your out-of-pocket maximum, your insurance pays for covered care.
Copays usually don't count toward your deductible. They do count toward your out-of-pocket maximum. Each plan applies these a little differently.
To see how your insurance applied them to an appointment, read After your appointment: claims, EOBs, and charges.
Which benefits apply to a Circle Medical appointment?
Video appointments. Your appointment uses your medical benefits. Some insurance covers video appointments differently from in-person appointments, or only covers in-person appointments.
Annual physicals or checkups. Many plans cover one preventive exam every 12 months, often at $0. See Annual physical (wellness exam).
HMOs. Your insurance may need a referral from your assigned primary care provider before we can bill it. See How to get your HMO referral or student health plan authorization.
Prescriptions. These use your pharmacy benefits. A medication can be covered and still need a prior authorization. See How prior authorizations work at Circle Medical.
Lab tests. The lab bills you or your insurance, not Circle Medical. See How lab orders and testing work.
How do I check what I might owe before I book?
You can get a free cost estimate before you book, including before you create an account. Enter your information exactly as it appears on file with your insurance.
The estimate is not your final invoice. It uses limited information from your insurance, so it can be missing or different from what you owe. Your insurance sets the final amount after the appointment.
If you want to confirm the estimate, call your insurance:
Find your provider's National Provider Identifier (NPI) and our Tax ID on the insurance page. Your insurance uses them to look up Circle Medical.
Call the member services number on your insurance card.
Ask the questions below, and write down the answers.
On the call
Have your insurance card with you.
Ask the representative to slow down, repeat something, or explain a term you don't understand.
Write down their name and a call reference number.
Ask them to email or mail you what they confirmed about your coverage.
Questions about your appointment
Is my Circle Medical provider in-network with my plan?
Are video appointments covered? Do they cost the same as in-person appointments?
What will I pay for a video appointment with a primary care provider? Is it a copay or coinsurance?
How much of my deductible is left this plan year?
Is the health concern I want to talk about covered?
Is a video wellness exam covered once a year?
Do I need a referral before I book?
Can the support team check my benefits?
No. Our support team cannot confirm the exactly details of your insurance plan. Only your insurance can confirm them.
You may also see a cost estimate when you book. If it is missing or different from what you expected, see Trouble verifying your insurance.
Still have questions?
For questions about your benefits or coverage, call your insurance. For questions about a Circle Medical invoice, reach out to support.