I'm sick. What should I know about my insurance plan?

Let’s face it – most people don’t care to understand their insurance plan until they need it. But once you’re sick, how do you know what costs you’re facing? No matter the circumstance, it’s important to know each part of your plan and what costs pertain to you.

What is a copay?

This term is used to describe the out-of-pocket costs to the consumer at the time of a specific service. If your copay for primary care is $20, you will pay that $20 every time you visit the doctor. Many plans also have a copay on prescriptions that will be paid each time a prescription is filled.

Great. So what is this deductible thing about?

A deductible is the predetermined amount the consumer must pay for eligible healthcare costs before the plan begins to contribute towards paying costs. Let’s say you need a carpal tunnel syndrome surgery and use your insurance plan with a $1,000 deductible. If the surgery costs $1,500, you will pay $1,000 and the insurance would then contribute to the balance.

But I still got a bill after I met my deductible. Why?

Coinsurance is another provision in most plans. This is the predetermined percentage of costs which the consumer is responsible for paying after the deductible is met. Let’s say you have a different surgery costing $25,000 total and you have met your deductible (from the previous wisdom teeth surgery). Your plan may have a 10% coinsurance and in that case, you will be billed $2,500 while the insurance pays $22,500.

That seems like a lot of costs! How much more do I have to pay?

The great part of many insurance plans is an out-of-pocket maximum clause. This is, as it says, the maximum amount the consumer pays out of their own pocket toward eligible healthcare costs. Let’s say you have yet another surgery this year, this time costing $50,000. Whoa – you don’t want to pay another $5,000 dollars. Well, you’re in luck. Your specific plan may have an out-of-pocket maximum of $5,000 for the year, meaning that is the limit.

When you put it altogether, you are paying $1,000 toward the deductible, $50 coinsurance for your carpal tunnel surgery and $2,500 for your second surgery. That’s $3,550 already. If you were charged full coinsurance for this surgery, it would be $5,000, but with the out-of-pocket maximum, you will only be required to pay $1,450.

We hope you don’t need that many surgeries, but it is always a good idea to know what you are responsible to pay versus what your insurance plan pays.