Cost sharing explained.
No matter which plan you choose, you can anticipate how you and your plan share the costs for your coverage. Here's a break down of how it works.
COSTS TO USE SERVICES
- You Pay 100%. Expect to pay 100% of costs for most care services until you meet your deductible amount.
- You & your plan pay. Once you meet you deductible amount, your plan begins to share costs. Often referred to as coinsurance, the plan pays a higher percentage o fcovered costs, and yo upay the remaining percentage.
- Your plan pays 100%. Once you meet your out-of-pocket limit, your plan pays 100% of covered health costs for the rest of the year.
Along the way, you may also pay a fixed amount - or copay - for things like visits to your primary care physician. Copays count toward your out-of-pocket limit.
You pay a set amount to have insurance (your premium).
To have health insurance, you and/or your employer pay a set amount called a premium , usually deducted from your employee paychecks. Think of paying your premiums like the membership fee you'd pay to belong to a gym.
1. You also pay to use any services, until you meet your deductible amount.
Once you begin seeing the doctor or using any medical services, most plans ask you to pay for care until you meet your deductible amount. Note that you may not be required to pay for certain routine care services. If your plan requires copays, keep in mind, they may not count toward your deductible.
How do family deductibles work?
Some plans will have a family deductible amount and an individual deductible amount. Check to see if your plan will begin to pay when you meet your individual deductible or the family deductible. These are called embedded deductibles or non-embedded deductibles.
Does your plan require a copay?
Some plans won’t require you to meet a deductible amount but you will pay a copay (a fixed amount for things like office visits). Some plans require meeting a deductible amount and also paying copays. Review your plan options to see how this may affect cost sharing.
2. If you meet your deductible, you and your plan share the responsibility to pay.
If you meet the plan's deductible amount, your plan starts to share costs. Often referred to as coinsurance, each plan agrees to pay a percentage of the cost. Generally, the plan pays 80% of costs, and you pay the remaining 20%.
3. If you meet your out-of-pocket limit, your plan pays everything.
If you reach the plan’s out-of-pocket limit amount, your plan pays all costs covered under the plan for the remainder of the year. Your amount includes what you paid for services until this point, but does not include your premiums.
Consider how you’ll use your plan
It's important to think about how cost sharing applies to the way you use your plan. When comparing plans, you’ll want to determine how much coverage you think you need and how it affects your costs.
Do you use health services fairly often?
Consider a plan that begins cost sharing faster.
Because health insurance doesn’t start to cover costs until you meet your deductible, you’ll want to pay special attention to each plan’s deductible amount and out-of-pocket limit to determine when the plan starts to help cover costs.
Do you use health services occasionally?
Consider your comfort level between cost and coverage.
If you don’t think you’ll need much coverage, you might choose the less expensive option where you pay less in monthly premiums. However, with a lower-premium plan, it usually takes a lot longer to reach the cost-sharing phases. If you or your family need unexpected care, a low-premium plan may not offer the coverage you need. So, be sure to consider your comfort level of both cost savings and coverage.