Cost-Sharing: Know What You May Owe
Health insurance protects you from paying the full cost of your care. But, you will likely still have to pay some money out of your pocket. Almost all plans call for “cost sharing.” That means your insurer pays for part of your care, and you pay for part. The costs may include:
Premium. A payment to buy and keep up your coverage, often made on a monthly basis. If you have coverage through your job, your employer may pay part or all of your premium.
Deductible. A set dollar amount you must pay out of pocket each year before your plan starts paying for services. Plans may have separate deductibles for individuals and families, or for types of coverage like medical care or prescription drugs.
Copay (or copayment). A fixed dollar amount for each doctor visit or service, such as $20 to visit your primary care physician (PCP). Copays may be higher for some services. For instance, you may pay $20 to visit your family doctor, but $30 for a specialist. Some preventive services, like yearly health exams, flu shots and mammograms, may not need a copay.
Coinsurance. A percentage of the cost of a service (for example, you pay 20 percent, your plan pays 80 percent).
Other things may affect your costs:
Out-of-network providers do not have a contract with your plan. They may charge more than your plan will pay (the plan’s “allowed charge”) for a particular service or type of care. Or, your plan may not pay, or may pay less, for out-of-network care. You will have to pay the difference.
Covered services are treatments your plan covers. Most plans do not cover services like over-the-counter drugs or cosmetic services, or services they believe are unproven or “experimental.”
The out-of-pocket limit is the most money that your insurer requires you to pay over a certain period, usually a year. After you reach this limit, your plan will pay the full cost of covered services. But, they will only pay up to the dollar amount of the allowed charge for that service. Your limit may differ for in-network and out-of-network services.
Having health insurance can help protect you
from paying for the full cost of your care
But, it doesn’t mean you won’t have to pay anything out of your pocket when you go to the doctor. Almost every plan involves “cost-sharing,” which means that your insurer pays for a portion of your care, and you pay a portion.
The amount you will have to pay out of your pocket depends on the type of plan that you have, and whether or not you use a provider who is contracted with your plan’s network. If you go “out-of-network,” you may have a greater number of providers to choose from, but your costs will likely be higher. It’s important to remember that providers aren’t just doctors. Your plan also contracts with hospitals, labs, radiology facilities and pharmacies – they are providers too. When you need care, it’s important to know if each of these providers is in your plan’s network or not, in order to anticipate what you may be required to pay.