Understanding Out-of-Pocket Costs for Joint Pain Treatment: Complete Guide

Decoding Medical Costs: What You Actually Pay

Medical billing is confusing by design. Between deductibles, copays, coinsurance, and out-of-pocket maximums, it’s hard to predict what you’ll actually owe for joint pain treatment.

This guide breaks down exactly what each term means, how costs add up, and what you can do to manage expenses.

The Four Key Terms You Need to Understand

1. Deductible

What it is: The amount you must pay out-of-pocket for covered services before your insurance starts sharing costs.

How it works:

• You pay 100% of costs until you meet your deductible
• Then your insurance begins paying its share
• Resets annually (usually January 1)

Example:

• Your plan has a $1,500 deductible
• You’ve paid $1,000 toward it this year
• HA injection costs $800
• You pay: $500 to meet remaining deductible + coinsurance on remaining $300
• After this treatment: Your deductible is met for the year

Common deductible amounts:

2. Copay (Copayment)

What it is: A fixed dollar amount you pay for a specific service.

How it works:

• You pay the copay at time of service
• Insurance pays the rest
• Usually applies after deductible is met (but not always)
• Varies by service type

Example:

• Your plan has a $50 specialist copay
• HA injection office visit
• You pay: $50 regardless of actual cost
• Insurance pays: Remainder

Common copay amounts:

Key distinction: Copays are fixed amounts, not percentages.

3. Coinsurance

What it is: The percentage of costs you pay after meeting your deductible.

How it works:

• Expressed as a split (e.g., 80/20, 70/30)
• First number = what insurance pays
• Second number = what you pay
• Applies after deductible is met

Example:

• Your plan has 80/20 coinsurance
• HA injection series approved amount: $800
• Deductible already met
• Insurance pays: 80% = $640
• You pay: 20% = $160

Common coinsurance splits:

Key distinction: Coinsurance is a percentage, not a fixed amount.

4. Out-of-Pocket Maximum (OOP Max)

What it is: The most you’ll pay for covered services in a plan year. After you reach this limit, insurance pays 100%.

How it works:

• Includes: Deductibles, copays, coinsurance
• Does NOT include: Premiums, non-covered services, out-of-network balance billing
• Resets annually
• Provides catastrophic protection

Example:

• Your OOP max: $5,000
• You’ve paid $4,700 in medical costs this year
• HA injection series with 20% coinsurance would be $160
• You pay: $160
• Running total: $4,860 toward OOP max
• Protection: If you need surgery later this year, you only pay $140 more before hitting OOP max

Common OOP maximums:

How Costs Add Up: Real-World Examples

Example 1: Original Medicare (Part B)

Your situation:

• Original Medicare (no Medigap)
• Part B deductible not yet met
• HA injection series Medicare-approved amount: $800

Your costs:

1. Part B deductible: $240 (first)
2. Remaining amount: $800 - $240 = $560
3. 20% coinsurance: $560 × 20% = $112
4. Total you pay: $240 + $112 = $352

If deductible already met:

• You pay: 20% of $800 = $160

Example 2: Medicare Advantage with Copays

Your situation:

• Medicare Advantage plan
• $50 specialist visit copay
• $100 outpatient procedure copay
• No deductible on your plan

Your costs:

1. Office visit copay: $50
2. Injection procedure copay: $100
3. Total you pay: $150

Note: Copay structure often results in lower, more predictable costs than Original Medicare.

Example 3: Commercial Insurance with Deductible Not Met

Your situation:

• Commercial insurance (Cigna, Aetna, etc.)
• $2,000 deductible (you’ve paid $500 so far)
• 80/20 coinsurance after deductible
• HA injection negotiated rate: $1,000
• In-network provider

Your costs:

1. Remaining deductible: $1,500 needs to be met
2. You pay toward deductible: $1,000
3. Your deductible status after: $1,500 total paid (only $500 remaining)
4. Total you pay: $1,000

Note: Early in the year before deductible is met, you may pay full cost.

Example 4: Commercial Insurance with Deductible Met

Same plan as Example 3, but deductible already met for the year:

Your costs:

1. Deductible: Already met
2. Coinsurance: 20% of $1,000 = $200
3. Total you pay: $200

This is why timing matters: Same treatment, $800 difference depending on when you have it done.

Example 5: Out-of-Network Provider

Your situation:

• Commercial insurance
• Deductible met
• In-network: 80/20 coinsurance
• Out-of-network: 60/40 coinsurance
• Out-of-network deductible: $4,000 (separate, not met)
• Provider charges: $1,200
• Insurance “allowed amount” for out-of-network: $800

Your costs:

1. Amount toward out-of-network deductible: $800
2. Balance billing: Provider can bill you for difference: $1,200 - $800 = $400
3. Total you pay: $800 + $400 = $1,200

Note: Out-of-network can result in paying FULL cost even with insurance.

Example 6: Near Out-of-Pocket Maximum

Your situation:

• Medicare Advantage plan
• OOP max: $5,000
• You’ve paid $4,850 this year
• HA injection copay: $150

Your costs:

1. Amount to OOP max: $5,000 - $4,850 = $150 remaining
2. Copay: $150
3. You pay: $150
4. Result: You’ve now hit OOP max
5. All future care this year: $0

Strategic timing: If you’re close to OOP max, schedule additional needed treatments before year-end.

Medicare Part B vs. Part D: Which Covers What?

Understanding the difference between Part B and Part D is essential for knowing what you’ll pay.

Medicare Part B (Medical Insurance)

Covers:

• Doctor visits
• Outpatient procedures
• Joint injections (HA, cortisone)
• Physical therapy
• Durable medical equipment (braces, canes)
• Preventive services

You pay:

• $240 annual deductible (2025)
• 20% coinsurance (no limit)
• Monthly premium: $185 (standard, 2025) or more based on income

Medicare Part D (Prescription Drug Coverage)

Covers:

• Prescription medications you pick up at pharmacy
• Some injectable drugs if self-administered at home

Does NOT cover:

• Medications given in doctor’s office or clinic
• Joint injections (these are Part B)

You pay:

• Plan-specific premiums, deductibles, copays
• Coverage “phases” (deductible, initial coverage, coverage gap, catastrophic)

Common Confusion: Why Joint Injections Are Part B

Many patients ask: “Can I use Part D for joint injections?”

Answer: No. Here’s why:

• Part D covers retail pharmacy prescriptions
• Joint injections are procedures performed by a physician
• Even though HA is technically a “drug,” it’s administered in a clinical setting
• All physician-administered drugs are covered under Part B, not Part D

Examples:

What Happens When Treatment Isn’t Covered

Sometimes insurance won’t cover a treatment at all:

• PRP injections (considered experimental)
• Stem cell treatments (lack evidence)
• Treatments exceeding frequency limits
• Services excluded from plan

Your Options

1. Pay Out-of-Pocket (Self-Pay)

Advantages:

• Proceed with treatment you want
• No insurance delays or denials
• May negotiate cash-pay discount

Disadvantages:

• 100% out-of-pocket cost
• Doesn’t count toward deductible or OOP max
• Can be expensive ($500-$1,500+ for HA injections)

How to reduce self-pay costs:

• Ask for cash-pay discount (often 20-30% less)
• Compare prices between providers (can vary significantly)
• Ask about payment plans
• Use HSA/FSA funds if available

2. Appeal the Denial

If insurance denies coverage but you believe treatment should be covered:

• Request written denial with reason
• Gather supporting documentation
• File formal appeal with deadline
• May include peer-reviewed research
• Success rate varies by reason for denial

See our Prior Authorization Guide for detailed appeal strategies.

3. Explore Financial Assistance

Manufacturer assistance programs:

• Some HA injection manufacturers offer patient assistance
• Usually based on income and insurance status
• May provide treatment at reduced cost or free

Provider payment plans:

• Many clinics offer interest-free monthly payments
• Spread cost over 6-12 months
• Ask before treatment: “Do you offer payment plans?”

Nonprofit assistance:

• Patient Advocate Foundation: 1-800-532-5274
• HealthWell Foundation
• Disease-specific foundations

4. Consider Alternative Treatments

If cost is prohibitive:

• Ask about covered alternatives
• Physical therapy may be covered with lower copay
• Cortisone injections often less expensive than HA
• Conservative treatments (exercise, weight loss) are low-cost

In-Network vs. Out-of-Network: The Cost Difference

Using in-network providers can save hundreds or thousands of dollars.

In-Network Providers

How it works:

• Provider has contract with your insurance
• Agrees to accept negotiated rates
• Insurance processes claims directly
• You pay only your cost-share (copay/coinsurance)

Your costs:

• Lower deductible applies
• Better coinsurance (e.g., 80/20 vs. 60/40)
• No balance billing
• Copays available on some plans

Example:

• HA injection negotiated rate: $800
• 80/20 coinsurance (deductible met)
• You pay: $160

Out-of-Network Providers

How it works:

• Provider has NO contract with insurance
• Can charge higher rates
• May not file claims for you
• Balance billing is allowed

Your costs:

• Higher deductible (often separate)
• Worse coinsurance (e.g., 60/40 or 50/50)
• Balance billing: You pay difference between provider charge and insurance “allowed amount”
• May need to file claims yourself

Example:

• Provider charges: $1,500
• Insurance “allowed amount”: $800
• 60/40 coinsurance (deductible met)
• Insurance pays: 60% of $800 = $480
• You pay: $320 (40% coinsurance) + $700 (balance bill) = $1,020

The Balance Billing Trap

What is balance billing? When out-of-network provider bills you for the difference between their charge and what insurance pays.

Example of how it adds up:

Difference: $860 more for out-of-network

How to Find Out What You’ll Pay

Before Treatment: Get a Cost Estimate

Step 1: Call your insurance (number on back of card)

Ask these questions:

1. “What is my deductible and how much have I met?”
2. “What is my out-of-pocket maximum and how much have I paid toward it?”
3. “Is [provider name] in-network?”
4. “What is my copay or coinsurance for this procedure?”
5. “Do I need prior authorization?”

Step 2: Ask your provider’s billing office

Ask these questions:

1. “What is the procedure code you’ll bill?” (Usually CPT 20610 for injection + J code for HA product)
2. “What will the total charge be?”
3. “What is the negotiated rate with my insurance?”
4. “Can you provide a cost estimate for my specific plan?”
5. “What will my out-of-pocket cost be?”

Step 3: Request pre-determination (optional)

Some plans offer “pre-determination of benefits”:

• Formal cost estimate before treatment
• Based on your specific deductible status
• Not a guarantee but helpful for planning
• May take 5-10 business days

Reading Your EOB (Explanation of Benefits)

After treatment, you’ll receive an EOB (not a bill):

Key sections:

1. Provider charge: What doctor billed
2. Allowed amount: What insurance approved
3. Insurance paid: What your plan paid
4. You owe: Your responsibility

Common EOB terms:

• Not covered: Treatment not included in benefits
• Applied to deductible: Counted toward your deductible
• Coinsurance: Your percentage
• Copay: Your fixed amount
• Processed as out-of-network: Provider wasn’t in-network

Red flags:

• Amount you owe is much higher than expected
• Service processed as out-of-network when provider should be in-network
• Denial for “not medically necessary” when prior authorization was approved
• Duplicate charges

What to do if EOB shows error:

• Call member services immediately
• Reference claim number
• Have documentation (prior authorization, network verification)
• Request claim review or reprocessing

Strategies to Reduce Your Costs

1. Time Treatments Strategically

Late in the year (if deductible met):

• Schedule treatments before January 1
• You’ll pay only coinsurance
• Deductible resets January 1

Late in the year (if close to OOP max):

• Schedule additional needed treatments
• Once you hit OOP max, insurance pays 100%

Early in the year (if deductible not met):

• May want to wait if possible
• Consider whether you’ll meet deductible through other care
• Evaluate total annual medical spending

2. Use In-Network Providers

• Verify network status before every appointment
• Use insurance website provider directory
• Call provider: “Are you in-network with [plan]?”
• Saves hundreds to thousands

3. Ask About Cash-Pay Discounts

If paying out-of-pocket:

• Providers often offer 20-40% discount for upfront cash payment
• Negotiate before treatment
• Ask: “What is your cash-pay rate?“

4. Utilize HSA or FSA

If you have Health Savings Account or Flexible Spending Account:

• Use pre-tax dollars for medical expenses
• Includes deductibles, copays, coinsurance
• May include OTC pain relievers and braces
• Contributions reduce taxable income

2025 HSA contribution limits:

• Individual: $4,300
• Family: $8,550
• Age 55+ catch-up: $1,000

5. Consider Timing of Supplemental Insurance

If you have Original Medicare:

• Medigap policies can cover Part B coinsurance
• Must enroll during open enrollment period (6 months from Part B start)
• Later enrollment may face underwriting

Evaluate cost:

• Medigap premium vs. expected 20% coinsurance costs
• Makes sense if you have significant medical needs

6. Apply for Financial Assistance

Manufacturer programs:

• Contact HA injection manufacturers
• May offer patient assistance based on income
• Free or reduced-cost treatment

Hospital/clinic charity care:

• Many non-profit providers offer financial assistance
• Based on income (often 200-400% of federal poverty level)
• May reduce bill by 50-100%
• Ask: “Do you have a financial assistance policy?“

7. Set Up Payment Plan

Most providers offer:

• Interest-free monthly payments
• 6-12 month terms common
• Avoid medical credit cards (high interest)
• Negotiate before treatment when possible

Understanding Medical Bills

Bill vs. EOB

EOB (Explanation of Benefits):

• From insurance company
• Not a bill
• Shows what was charged, what was covered, what you owe
• May arrive before actual bill

Bill:

• From provider or facility
• This is what you owe
• Should match “patient responsibility” on EOB
• May offer payment options

What to Do If Bill Doesn’t Match EOB

Step 1: Compare carefully

• Provider charge should match
• Your responsibility on EOB should match bill amount
• Check dates and service descriptions

Step 2: If there’s a discrepancy

• Call provider’s billing office first
• Reference EOB and explain difference
• Often billing errors that can be corrected

Step 3: If billing office won’t correct

• Call insurance member services
• Explain the discrepancy
• Request claim review
• Get reference number

Step 4: Don’t ignore bills

• Contact provider even if disputing charges
• Explain you’re working with insurance to resolve
• Unpaid bills can go to collections

Common Questions About Out-of-Pocket Costs

”Why did I pay more than my friend with the same insurance?”

Possible reasons:

• Different plan designs (even within same insurance company)
• Different deductible status (they met theirs, you haven’t)
• Different OOP max progress
• Different providers (one in-network, one out)
• Different time of year (affects deductible/OOP status)

“Why am I paying full cost even though I have insurance?”

Most likely reason: Deductible not yet met

How it works:

• You pay 100% of costs until deductible is met
• This is normal and expected early in plan year
• Costs do count toward deductible
• Once met, insurance begins cost-sharing

”Can I negotiate medical bills?”

Yes, in some situations:

Before treatment:

• Ask about cash-pay discounts (20-40% common)
• Compare prices between providers
• Negotiate payment plans

After treatment:

• If bill is large and you’re struggling to pay
• Ask about financial assistance programs
• Request payment plan
• Some providers will negotiate reduction

Don’t negotiate:

• Insurance-negotiated rates (already set by contract)
• Bills that insurance is processing

”What if I can’t afford to pay?”

Options:

1. Contact provider immediately

   • Explain financial hardship
   • Ask about financial assistance
   • Request payment plan

2. Apply for assistance programs

   • Hospital charity care
   • Manufacturer patient assistance
   • Nonprofit organizations

3. Never ignore bills

   • Can damage credit
   • May go to collections
   • Communicate with provider even if you can’t pay full amount

”Do all costs count toward my out-of-pocket maximum?”

What counts:

• Deductibles
• Copays
• Coinsurance
• Some plans: prescription copays

What does NOT count:

• Monthly premiums
• Non-covered services
• Out-of-network balance billing (on some plans)
• Services outside plan network (HMO plans)

Key Takeaways

1. Four cost-sharing mechanisms: Deductible, copay, coinsurance, out-of-pocket max
2. Timing matters: Same treatment costs different amounts depending on deductible status and time of year
3. In-network saves money: Can be difference of hundreds to thousands of dollars
4. Part B covers joint injections: Not Part D, even though HA is technically a drug
5. Get cost estimates: Call insurance and provider before treatment
6. Financial assistance exists: Manufacturer programs, charity care, payment plans
7. Read your EOB carefully: Catch errors before bills become collections
8. Don’t ignore bills: Communicate with providers even if you can’t pay full amount

Related Resources

• Prior Authorization Guide - Understanding the PA process
• Medicare Coverage - Original Medicare costs and coverage
• Medicare Advantage - MA plan cost structures
• Cigna Coverage - Commercial insurance example
• Hyaluronic Acid Injections - Treatment overview
• How to Choose a Provider - Finding quality, affordable care