When considering your health coverage options, these are the main cost factors you should consider.
The deductible is the amount you owe during a coverage period (usually one year) for covered health care services before your plan begins to pay. The deductible may not apply to all services. If you have a family, many plans have both an Individual Deductible and a Family Deductible. Check the plan to see how cost-sharing works when you meet one or both deductibles. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health services subject to the deductible
Most coverage options have a premium—the amount you pay, usually monthly, for your plan. Premiums are a fixed amount you pay, whether you use health care services or not.
Copayment (or Copay)
In addition to paying your premium, a copayment, or copay, is the fixed amount you pay each time you see a network provider including for doctor’s visits, specialists’ visits, ER visits, and often for prescription drugs. Some plans require you to pay copays instead of meeting a deductible. Other plans may require you to pay both a copay and meet a deductible. Keep in mind, copays do not count toward the deductible amount, but do count toward your out-of-pocket limit.
Coinsurance is the amount shared by you and your plan for health care costs, calculated as a percentage. For example, if the health plan’s allowed amount for an office visit is $100, and you’ve met your deductible, your coinsurance payment of 20% would be $20. Your health plan would pay the rest of the allowed amount.
The out-of-pocket limit (OOPL) is the total amount of health costs you are responsible for before your plan pays 100% of covered health costs for the rest of the year. If you have a family, some plans include both an Individual OOPL and Family OOPL. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges or health care your plan doesn’t cover. Generally, copays, your deductible, coinsurance and covered network payments count toward this limit.