If you have health insurance or are in the market for an insurance plan, you may be feeling terminology overload. What is a deductible? What is coinsurance? How does a Co-pay work? What is an insurance Premium? Individual out of pocket maximum? In this video, we’re going to break down these essential health insurance terms, explain how the costs work for both you and your insurance company, and hopefully help you feel more confident about how your plan works.
Table of Contents:
0:00 – Intro
0:30 – Overview
1:01 – Your Expenses
1:28 – Insuranace Premium
1:43 – What is a Deductible?
3:13 – What is Copay?
3:50 – FREE Services
4:03 – What is Coinsurance?
4:40 – Individual Out of Pocket Maximum (OOP)
5:00 – Family OOP Max
5:08 – Review
There are 3 levels of health care costs. The higher your costs for the year, the higher up you go. Level 1, You’re paying everything. When your healthcare expenses get to a certain point, you enter Level 2, where you and your insurance company share the costs. If the money you’re paying out of your pocket hits your plan’s cap, you enter Level 3, where your insurance will cover everything further. We’ll circle back to this at the end and it’ll all make more sense.
Now, whether your health insurance is provided through your employer plan, by someone else’s employer plan, self-pay, or a government-issued plan like Medicare or Medicaid, they all have set amounts for premiums, deductibles, co-pay, and co-insurance. These are all terms that represent your out of pocket costs.
🔵 Premium. Think of your Premium like a monthly subscription fee. This is how much you pay each month to keep your insurance active. You pay this even if you never go to a doctor.
🔵 Deductible. Your deductible is an amount 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 $4000, and the bill for your visit to the hospital was $2000, you have to pay 100% of that bill. Bummer.
But if your deductible is set at $4000 and the hospital bill is $8000, insurance would kick in to help cover half of that bill. Notice that I said it will “help cover” half of that bill…”help.” More on that later. Once you have paid that amount toward covered medical expenses, you’re good until your plan renews. (Usually January 1st)
🔵 Co-Pay. Your co-pay is a set cost you pay for a covered health care service, such as visiting an in-network 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 co-pay of $50 for doctor’s visits. You pay the $50 and your insurance picks up the rest.
🔵 Co-Insurance. Remember when I said that insurance will “help cover” costs that exceed your deductible? That’s where co-insurance comes in. Co-insurance 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.
🔵 Individual Out of Pocket (OOP) Maximum: The amount of money that you pay through co-pays, co-insurance, and deductibles. This is your plan’s cap on how much you have to personally pay toward your healthcare costs. After that, 100% is covered by your insurance.
🔵 Family out of pocket max: A cap on the medical costs for a family. After that, your insurance covers the rest for the entire family.
Now let’s bring back the 3 levels example from the beginning. You start on level 1, paying basically everything out of pocket…that is until you reach your deductible. That’s when you go to level 2, where you split the cost with your insurance company through Co-Insurance. 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 3 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.