You have a healthcare plan, but do you understand it? Understanding how it works can help you take advantage of everything your plan has to offer.
- What is a Copay?
A copay is the predetermined, fixed-rate you pay for health care services at the time of care. These amounts are listed on your medical plan summaries. For most plans, such services include, but not limited to, Prescription drugs, Dr. Visits, Specialist visits, lab work, X-rays, Urgent Care, Emergency room and
- What is a Deductible?
The amount the participant pays for services that do not include a co-pay. There are both individual and family deductible amounts. PPO plans typically offer both an in-network deductible and out-of-network deductibles and they are not combined to reach your deductible limits.
Note: always stay with an in-network provider to keep your costs down and to pay the least out of pocket.
- What is Co-Insurance? The percentage of costs for a covered health care service you pay after you’ve paid your deductible and is shared with the insurance carrier (80/20) (100) (70/30) (60/40)(50/50)
The lower the co-insurance on the participant side, the more they must pay at the time of service until they reach the out of pocket maximum.
What is an Out of Pocket Maximum?
An out-of-pocket maximum is the cap, or limit of money you have to pay for covered health care services in a plan year. Once you meet this limit and you stay with an in-network provider, your health plan will pay 100% of all covered health care costs for the rest of the plan year.
The above are in order of how most health plans apply the participant’s medical cost for services.
Note: Some variations do apply.
HMO, PPO, MCPOS and EPO plans are typically co-pay driven plans
High Deductible health plans (HDHP) typically have no co-pay amounts and the participants pay out-of-pocket for all services until they hit the deductible, then co-insurance and out of pocket maximum limits. Once those are reached, the plans pays 100% of services for that year.