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For private insurance, the annual deductible is the amount paid each year before the insurance company starts paying its share of the costs.
A co-pay, or co-payment, is the fixed amount paid at each visit to a care provider or for each prescription filled. Not all plans require co-pays. Co-pays may vary for primary care visits, specialty visits, or type of prescription filled.
The co-insurance is the percentage paid for certain medical expenses after the deductible is met. An insurance company pays a portion of care expenses. The family is responsible for the remaining amount.
The out-of-pocket maximum is the maximum amount paid each year for covered medical expenses. It may be calculated separately for individual and family insurance coverages.
These documents include Summary Plan Descriptions (SPD) or Evidence of Coverage (EOC) or Summary of Benefits Coverage (SBC)
The insurance network is the group of doctors, hospitals, pharmacies, and other health care providers that the insurance company contracts with to provide services.
If a provider is not in a specific network, the insurance company may not pay for the services provided. Or the family may pay more for the services. Understanding which providers are included in your health plan’s network of providers will minimize surprise expenses.
A premium is the amount the family pays each month for health coverage. If the family has a plan with lower monthly premiums, they will likely pay more for health expenses before the insurance starts sharing costs. Plans with higher monthly premiums usually mean lower out-of-pocket expenses.
Consider all potential out-of-pocket costs when reviewing health insurance options.
Reviewed: June 2018