With health insurance season and the end of the year is just around the corner, many Americans are beginning to look at their current insurance. I was attending my book club just last night when one of the women began to talk about trying to fit in some procedures this year since she’d already met her deductible. This is a common mindset when it comes to your health insurance, but so often, the terms the insurance company uses can be confusing. That’s where we come in to help you understand.

$35 Copay: Specialist Visit: $80 Copay after deductible: Laboratory Outpatient and Professional Services: $40 Copay after deductible: X-rays and Diagnostic Imaging: $80 Copay after deductible: Diagnostic Imaging such as MRIs, CT, and PET scans: 40.00% Coinsurance after deductible: Deductible - Family: $12800 per group: Out-of-Pocket Maximum - Family: $15800 per group. But with full coverage for long-term care, most dental care included, no deductibles and zero copays, the Sanders plan is considerably more generous. Think of it as Medicare on growth hormones. A no-deductible health insurance policy does not require the policyholder to pay anything out of pocket before the insurance kicks in. No- deductible health insurance is a kind of health insurance that doesn’t include a required up front payment by the enrolled member each year. Copays and deductibles are both features of health insurance plans and dictate how much the insured pays for health services, though amounts and frequencies vary. A copay is a fixed amount paid by a patient for receiving a particular health care service, with the remaining balance covered by the person's insurance company.

Copays

What is a Copay?

A copay (also referred to as a copayment) is a small, flat charge that you pay after each Dr. visit or fill a prescription. For example, if you tweak your knee and go visit the Dr. the amount they charge for the visit is your copay. The amount that you have to pay is typically list on your Health ID Card. Often, a Copay can be broken into General visits and Specialist visits, with the specialist costing you a bit more. Copays cover your portion of the cost of a doctor’s visit or medication.

Will I Always Have a Copay?

Not always. Not all health care plans have copays as a part of their plan. Some plans may use both copays and a deductible/coinsurance, depending on the type of covered service. Also, some services may be covered at no out-of-pocket cost to you, such as annual checkups and certain other preventive care services.

Deductibles

What is a Deductible?

A deductible is amount you are responsible for each year for most covered medical services or medications before your health insurance provider will kick in and pay a portion of covered services. For example, if you have a $2,000 yearly deductible, you’ll need to pay the first $2,000 of your total eligible medical costs before your plan helps to pay.

Costs that typically count towards deductibles:

• Bills from a hospital stay
• Surgery
• Lab Tests
• MRIs & CAT scans
• Anesthesia
• Doctor visits not covered by Copay
• Medical Devices

Costs that don’t:

• Copays
• Premiums
• Expenses not covered

Deductibles for an entire family versus an individual are going to be different amounts. Even if your plan includes out-of-network benefits, your deductible amount will typically be much lower if you use in-network doctors and hospitals.

How Much Should I Choose for my Deductible Amount?

If you’re relatively healthy and don’t typically visit the Dr often for expensive medical procedures, a plan with a higher deductible and lower premiums may make the most sense for you.

On the other hand, if you know you have costly procedures that will have to be done this year or a medical condition that needs to be taken care of, a plan with a lower deductible and higher premiums that will pay more for your medical costs may be the answer for you. This may also be a good fit for active families that are involved in active sports.

What is the Difference Between a Deductible and a Copay?

A deductible is the amount you have to pay for covered services before the health insurance company will help chip in with the cost. If your plan includes copays, you pay the copay flat fee at the time of service (at the pharmacy or doctor’s office, for example). Depending on how your plan works, what you pay in copays may count toward meeting your deductible.

Coinsurance

What is Coinsurance?

Coinsurance is a percentage of the medical cost you’re responsible after your deductible has been met. Coinsurance is a way splitting the cost with your insurance company in an amount that equals 100%.

For example, if your coinsurance is 20 percent, you pay 20 percent of the cost of your covered medical bills. Your health insurance plan will pay the other 80 percent. If you meet your annual deductible in June, and need an MRI in July, it is covered by coinsurance. If the covered charges for an MRI are $2,000 and your coinsurance is 20 percent, you need to pay $400 ($2,000 x 20%). Your insurance company or health plan pays the other $1,600. The higher your coinsurance percentage, the higher your share of the cost is. You are also responsible for any charges that are not covered by the health plan, such as charges that exceed the plan’s Maximum Reimbursable Charge.

What is an the max-out of pocket (aka out-of-pocket maximum?)

Out-of-pocket maximum is the max amount you could pay for covered medical services in a year. The max out pocket will include money that you have spent on copays, deductibles, and coinsurance. Once you reach your annual out-of-pocket maximum, your health plan will pay the entire amount of your covered medical and prescription costs for the rest of the year.

Here’s an example.** You have a plan with a $3,000 annual deductible and 20% coinsurance with a $6,350 out-of-pocket maximum. You haven’t had any medical expenses all year, but then you need surgery and a few days in the hospital. That hospital bill might be $150,000.

You will pay the first $3,000 of your hospital bill as your deductible. Then, your coinsurance kicks in. The health plan pays 80% of your covered medical expenses. You’ll be responsible for payment of 20% of those expenses until the remaining $3,350 of your annual $6,350 out-of-pocket maximum is met. Then, the plan covers 100% of your remaining eligible medical expenses for that calendar year.

Depending on your plan, the numbers will vary—but you get the idea. In this scenario, your $6,350 out-of-pocket maximum is much less than a $150,000 hospital bill!

Health insurance can be confusing, but we can help make it easy. For a quote on your Oklahoma health insurance visit our website, text, or call our office at 405-373-2977.

Also Read:What You Need to Know About COBRA Insurance

No-deductible health insurance is a kind of health insurance that doesn’t include a required up front payment by the enrolled member each year. Rather than making the subscriber meet a minimum balance, health insurance with no deductible means the health insurance company will make payments up front, paying out for doctor visits, emergency care, or other events. The down side is that having this kind of policy means those who receive the insurance will generally pay more for it than they would if it included a health insurance deductible.

A lot of no-deductible health insurance plans are employer-based healthcare plans. There are many key differences between the majority of employer-based plans, and most of the self purchased health insurance plans on the market. One main difference is that employer-based plans are forced to cover active employees, where self-purchased plans can deny an applicant for many reasons. With employer-based plans, the higher costs to the individual subscriber, who is the employee, are offset by the fact that the employer is most often paying part of the cost of the policy.

No Deductible No Copay Health Insurance Coverage

On the other side of the spectrum, some self-purchased plans are the opposite of no-deductible health insurance. High-deductible plans make the subscriber pay up to several thousand for any medical care in a given year. The positive side to these plans is that premiums tend to be lower, and if the health care costs exceed a certain cap (the deductible plus other related costs) the health insurance will pay additional costs, allowing families to estimate their maximum annual out of pocket cost, and budget for medical emergencies. These kind of high-deductible plans are called “catastrophic” health insurance plans.

Health Insurance No Deductible Plans

In a rush to anticipate possible changes related to recent healthcare reform, a lot of insurance companies are changing the way they pursue policy offerings to consumers. Some of the newer plans may be no-deductible health insurance, and some may include significant deductibles. Both kinds of options will appeal to a certain kind of consumer or household, depending on how people like to budget their medical expenses