Health care plans-

Do they confuse you?

 

 

 


Here are some common terms that may help you.

Preventive care
}}Most plans cover 100% of the cost for yearly checkups, preventive tests and other things that keep
    you healthy.*
Copay (copayment)
}}When you see a doctor, most plans have you pay a certain amount to the doctor for the visit. It is a
     fixed dollar amount paid to your doctor.
}}This amount does not go toward your deductible or your out-of-pocket maximum.
Deductible
}}You pay this amount for covered services each calendar benefit year
    (January through December).
}}Covered services that would apply to the deductible may include labs, X-rays, anesthesia
    and surgeon fees.
}}Your deductible starts over (usually, but not always) each calendar benefit year.
Coinsurance
}}Once youíve met your deductible, the health care plan starts paying a portion of claims.
    (Preventive coverage starts before the deductible is met.)
}}The health care bills that remain are shared between you and your insurance company.
    This is called ďcoinsurance.Ē
}}Insurance Companies will pay between 50% and 100% of the bill.
Out-of-pocket maximum (max)
}}Every plan has an out-of-pocket maximum. The amount you pay in deductible and coinsurance are
    typically what make up your out-of-pocket maximum.
}}With some plans, you have to keep paying a copay for doctorís visits and prescriptions even after
    the out-of-pocket maximum is met.
}}Once you meet your out-of-pocket maximum, insurance companies pay 100% of covered services for the rest of the
    calendar benefit year. See your plan for details.
* The following preventive services, recommended by the United States Preventive Services Task Force, are covered
   at 100% when received in-network: well child care, immunizations, PSA screenings, pap tests and more. If you are
   on a grandfathered plan, your benefits may vary.
   In general, the lower your deductible, copay and/or coinsurance, the more your premium. Keep this in mind
   when youíre thinking about the right plan for you.

 

 

A plan in action

Jimís health plan has the following benefits:
}}$30 copay for doctor visits.
}}$2,000 deductible.
}}30% coinsurance (up to a limit of $3,000).
}}$5,000 out-of-pocket maximum.
After injuring his knee in a basketball game, Jim calls his doctor. He chooses a doctor in the health care plans network, which saves him the most money.
By choosing network doctors and labs, Jim gets lower negotiated rates (meaning, discounted prices). This example explains what happened, what Jim paid and why it is important to have health insurance.

What happened What Jim Paid
Jim visits the doctor Copay
Doctor visit cost (without insurance): $200
Health care plans negotiated rate: $140
Health care plan pays: $110
Jim pays: $30
$30.00
Tests and treatments Deductible
The doctor orders an MRI of the knee.
MRI cost (without insurance): $1,500
Health care plans negotiated rate: $1,000
Jim pays: $1,000
$1,000
Jimís payment counts toward his deductible.
Doctor recommends surgery.
Hospital/Surgery costs (without insurance): $50,000
Health care plans negotiated rate: $35,000
Jim pays: $1,000
Remaining cost of surgery: $34,000
$1,000
Jimís payment satisfies his remaining deductible.
Surgery costs continued Coinsurance
Having met his deductible, Jimís coinsurance begins.
Coinsurance: 30% (30% of $34,000 = $10,200)
Jim pays: $3,000
Remaining cost of surgery: $31,000
$3,000
Jim has a coinsurance limit so he only pays $3,000
instead of $10,200.
Remaining surgery costs are paid Out-of-pocket maximum
Health care plan pays: $31,000 $5,000
$2,000 deductible + $3,000 coinsurance
SUMMARY TOTAL JIM PAID
Total for doctor visit, MRI and surgery
(without health insurance)
$51,700
Total insurance paid after discounts $31,110
Total Jim paid $5,030
$5,030
(for doctor visit, MRI and surgery)

Note: This example of a plan in action is for illustrative purposes only and actual benefits of the plan will vary.