Insurance FAQs

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.

  • Many plans pay for certain services, like a checkup or disease management programs, before you've met your deductible. Check your plan details.
  • Some plans have separate deductibles for certain services, like prescription drugs.
  • Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members.

Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.

Source: HealthCare.gov

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.

  • If you've paid your deductible: You pay $20, usually at the time of the visit.
  • If you haven't met your deductible: You pay $100, the full allowable amount for the visit.

Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.

Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.

Source: HealthCare.gov

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.

  • If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
  • If you haven't met your deductible: You pay the full allowed amount, $100.

Source: HealthCare.gov

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

The out-of-pocket limit doesn't include:

  • Your monthly premiums
  • Anything you spend for services your plan doesn't cover
  • Out-of-network care and services
  • Costs above the allowed amount for a service that a provider may charge

Source: HealthCare.gov