How Health Insurance Works If you have a health insurance plan or you’re in the market for insurance, you may be feeling a bit overwhelmed and maybe confused by all the terms being used copay, deductibles, premiums, coinsurance, individual out of pocket maximum adds the fact that many of these can vary widely based on the coverage or plan.
How Health Insurance Works
And you’ve got a lot to wrap your mind. In this video, we’re going to break down and demystify these essential health insurance terms, explain how the costs work for both you and your insurance company, and hopefully make you feel a bit more confident about how your plan works. So let’s get started.
Overview
How Health Insurance Works :Sort of the view from Ten 0ft is that there are three levels of health care costs, and the higher your cost for the year, the higher up you go.
Level one, level two, level Three on level one, you pay for everything. When your health care expenses get to a certain point, you enter level two, where you and your insurance company share the costs.
if the money you’re paying out of pocket hits your plans cap that you enter level three, where your insurance will cover everything. Further, we’ll circle back to this at the end. It will all make a little more sense.
Your Expenses
Now, whether your health insurance is provided through your employer plan, through somebody else’s employer plan, or government issued plan like Medicare and Medicaid, they all have a set amount for premiums, deductibles, copay, and coinsurance.
These are all terms that represent your out of pocket costs. If you don’t know what those figures are for your policy, contact your insurance company to request a copy of your policy. I just threw a bunch of times at you. Let’s define these suckers.
insuranace Premium
Premium think of your premium like a monthly subscription fee, like your Netflix subscription. This is how much you pay each month to keep your insurance active. And you pay this even if you never go to the doctor. Just like with Netflix, even if you don’t watch anything, you’re still paying your subscription, right?
What is Deductible
How Health Insurance Works Deductible your deductible is about specified by your plan that you have to pay in a given year before your insurance pays a dime.
For example, if your deductible is set at $4,000 and the bill for your visit to the hospital was $2,000, you have to pay 100% of that bill. Bummer. But if your deductible is set at $4,000 and the hospital bill is $8,000, insurance would kick in to help cover half of that bill. Notice that I said it will help. More on that later.
The good news is that this is an annual deductible, meaning that once you’ve paid that amount towards covered medical expenses, you don’t have to pay it again until your plan resets.
Often this is on January 1, but that’s not always the case. You should check with your insurance provider. When shopping for health insurance, it’s great to look for a plan with a low deductible. However, there is, of course, a tradeoff.
Plans that feature a low deductible come with higher monthly premiums, while plans with lower monthly premiums have high deductibles. So why choose one over the other? Well, it comes down to what you anticipate your usage will be.
If you usually go for one, maybe two doctor’s visits per year, you probably want a high deductible with low premiums. These are often referred to as catastrophic coverage plans because they aren’t going to kick in until something really significant or catastrophic happens.
On the other hand, if you visit the hospital a lot or you have some upcoming procedures, then you probably want to go with a high premium, low deductible plan. If you have a health insurance usage history, you can use that to help determine
What is Copay
which kind of plan is going to be best for you. Copay your copay is a set cost that you pay for a covered healthcare service, such as visiting an InNetwork doctor
a specialist or buying drugs. Let’s say you go to see your doctor who charges $250 for an office visit, but your insurance has a copay of $50. For doctor’s visits, you pay $50 and your insurance picks up the rest.
Well, hold on a second. How do copays work if I haven’t met my deductible yet? Because copays are paying for some of your medical expenses, doesn’t that not kick in until after you hit your deductible? Well, confusingly, it depends on your policy, so that’s something you really want to check on. Here’s a tip.
Free Service
Your insurance will likely have a list of preventative care benefits that they’ll cover at 100%. No copay, no deductible, no coinsurance. These often include vaccines and many types of screenings,
How Health Insurance Works so take advantage of those coinsurance. Remember when I said that insurance would help cover costs that exceed your deductible? That’s where coinsurance comes in.
What is Coinsurance
Coinsurance is a shared cost between you and the insurance company. So depending on your policy, it may say that after your deductible, you pay 20% and your insurance company pays 80%.
That’s called an 80 20 policy. Now, for the ease of math, let’s say you have a 50 50 policy with a $4,000 deductible and you just had an $8,000 Er visit. You pay the first $4,000 to meet your deductible, and then the second $4,000 would be split 50 50, meaning you pay 2000 of that.
individul out of pocket naximum
So for that $8000 Er visit, you’d be out $6,000. Individual out of pocket maximum outofpocket is the amount of money that you pay. This includes your copays, doctor’s visits, coinsurance, deductibles, drugs, and the out of pocket.
maximum is your plans cap on how much you have to personally pay towards your health care costs after you hit that maximum? 100% is covered by your insurance family out of pocket max. Based on what individual yearly out of pocket is, you can probably guess this one.
Famaily OOp Max
It’s the cap on the medical costs for a whole family. Now, let’s bring back the three levels. Example from the beginning now you start on level one, paying basically everything out of pocket. That is, until you reach your deductible. And that’s when you go to level two.
Review
And that’s where you’re splitting the cost with your insurance company through coinsurance. If your medical expenses get so high that the total of what you paid reaches your yearly out of pocket maximum, you move to level three, where all further healthcare expenses for the rest of the year are 100% covered by your insurance plan.
When your plan resets for the year, you start back at the beginning. Usually this happens on January 1, but some plans differ on their reset date. If you’re still feeling unsure about what this all means
or about your financial responsibility for your covered services, your local health care facility can often help you obtain and understand this information, especially when considering an upcoming service or appointment.
How Health Insurance Works
Hopefully, this post has helped you feel a little more comfortable with the cost involved. Your health insurance. Thanks for reading.
Read More: Top 15 Things You Didn’t Know About The Insurance Industry
