A health insurance plan pays a portion of the costs for covered items and services. The enrollee pays a part of those costs by paying deductibles, copayments and coinsurance.
These cost sharing amounts are called "out-of-pocket expenses" and count toward a maximum out-of-pocket limit under most plans. Premiums - the monthly payments you must make to keep your coverage in force - are not considered cost sharing charges under private or Medicare plans.
What is a deductible?
A deductible is the amount of money you must pay for health care costs before your insurance plan begins to pay for them. It’s one of the many ways that your health insurance provider helps you manage your out-of-pocket costs.
A deductible can be an important part of a health insurance plan, helping you get the most out of your coverage. Deductibles may be low or high, depending on the plan you choose.
The deductible you select should be based on how much medical care you expect to receive in a year, your ability to cover the cost of medical services before the deductible is reached and your budget.
You can find out more about your deductible and other cost-sharing details by reviewing the terms of your plan on the website or marketing materials for your health insurance company. Having a full understanding of how deductibles work will make it easier for you to select the best health insurance plan for your needs.
What is a copayment?
In health insurance, a copayment is a fixed amount that you pay for certain medical services. This fixed amount is typically specified in your plan, so you will know exactly how much to expect to pay for a specific service before you visit the doctor.
Some services, like prescription drugs and emergency room visits, have higher copayments than others. You can find more information about your copayments on your Blue Cross ID card or through our website or mobile app.
Copayments are one of many forms of cost sharing in health insurance plans. Understanding how this system works can help you make smart insurance choices that meet your healthcare needs and budget.
The most important thing to remember about copayments is that they are only part of what you pay out-of-pocket for your healthcare services before your health insurance plan begins to cover them. The other part of your out-of-pocket expenses is a deductible.
What is a coinsurance?
A coinsurance is a percentage of a health service or medical expense that you must pay after meeting your deductible. This amount is often specified in your plan's certificate of insurance, summary plan description (SPD) or other document.
You'll also see this information on the Explanation of Benefits (EOB) your health plan sends you after you receive care. For example, if you're treated at a hospital for a broken wrist that costs $1,200, you'll have to pay 20 percent of the bill.
This is a typical coinsurance arrangement for many plans. Typically, the insurer pays 80% and you pay 20% of your share.
Educating yourself about the terms copay, deductible and coinsurance can help you understand your policy and make informed decisions when it comes to purchasing coverage for yourself and your family. It can also help you save money and avoid unnecessary medical bills.
What is a maximum out-of-pocket limit?
The maximum out-of-pocket limit (also known as an OOP limit) in your health insurance plan sets a cap on the total amount of money you'll spend for covered services in one year. This maximum out-of-pocket limit is different from your deductible because it applies to all services you receive for the entire policy year.
When your total spending for covered services exceeds your deductible, you'll pay copayments and/or coinsurance until your spending reaches your out-of-pocket maximum. Once you reach your out-of-pocket maximum, your insurance company pays 100% of the cost for covered services.
The out-of-pocket limit is a key part of your health insurance policy and should be considered when making decisions about your plan. It can make a difference in how much you pay for medical care, especially if you have significant health issues.