It is important to understand how your health care plan operates, but far too often the tricky benefit jargon of “deductible, coinsurance, copay, and out-of-pocket max” get in the way. These hard to understand health care vocabulary terms are explained below to help make understanding your health care plan much simpler!
Deductible – the amount of out-of-pocket expenses you pay for covered health care services before the insurance plan begins to pay.
| HSA-Eligible Plan | All covered services require you to meet your deductible first and then services will be covered through coinsurance. |
| PPO Plan | Some covered services require you to meet the deductible first, while other covered services are paid with a copay. |
| Helpful Hint! | The health plan comparison chart shows deductible amounts for Tier 1, Tier 2 and Tier 3, but you should think of your deductible as one sum of the money you have paid for your services. |
| Example | With a $1500 Tier 1 deductible on the HSA-Eligible Plan with single coverage, you pay the first $1500 of covered services yourself. If you have met this, you would pay an additional $100 towards your services and then would have met the Tier 2 deductible of $2,500. |
Coinsurance – the percentage of cost of a covered health care service you pay once you have met your deductible.
An insurer without a co-pay clause will be taking all the risk on themselves, hence demand higher premium payments. National Insurance Co. Has a co-pay scheme that offers 10% discount on premium on acceptance of a 2% co-pay clause. FAQs about Co-Pay in.
| HSA-Eligible and PPO Plans | For services covered by “coinsurance after deductible” the amount you pay in co-insurance continues to count towards meeting your next Tier deductible. |
| Coinsurance % | Most Tier 1 services are covered at “90% coinsurance after deductible,” while Tier 2 services are “75% after deductible and Tier 3 are “60% after deductible.” |
| Example | If you are on either plan and have hit your Tier 1 deductible and visit a Tier 1 urgent care provider, the plan covers that service at “90% coinsurance after deductible.” This means you will pay 10% of the cost of the visit and your insurance will cover the remaining 90%. The 10% you pay will count towards your deductible. |
- A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. How it works: Your plan determines what your copay is for different types of services, and when you have one. You may have a copay before you’ve finished paying toward your deductible.
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- Copays and deductibles are both features of most insurance plans. A deductible is an amount that must be paid for covered healthcare services before insurance begins paying. Copays are typically.
No Copays During Covid
Copay – a fixed dollar amount you must pay to a provider at the time services are received.
| PPO Plan | Only the PPO Plan offers a copay option for specific covered services. Your copay does not count towards your deductible. |
| Copay Amounts | Copay amounts vary based on the plan design. The health plan comparison chart is the best resource to understand what your copay is for a covered service within any of the tiers. |
| Example | If you are on the PPO plan and you see a Tier 1 provider for a standard sick visit, then your copay at the time of the visit will be $20. If you seek a Tier 1 provider for physical therapy, then your copay will be $35. |
No Copay Medicare Prescription Plans
Out-of-Pocket Max – the maximum amount you pay each calendar year to receive covered services after you meet your deductible. Once you meet your out-of-pocket maximum, the Plan pays 100% of covered services you receive. In network and out-of-network services are subject to separate out-of-pocket maximums.
No Copay Means
| HSA-Eligible and PPO Plans | Your out-of-pocket max is the summation of everything you have paid for your medical services received; this includes deductible, coinsurance and copay. |
| Helpful Hint! | Out-of-pocket max’s are determined by coverage level (single vs plan with dependents) and salary. On the health plan comparison chart you will see multiple rows with Out-of-Pocket Max figures, so be sure to look in the row that pertains to your situation. |