What will I pay in addition to my premium?


Visual summary of cost sharing: Premium + Deductible +/or Co-Payment + Co-Insurance

As a way to control costs and reduce premiums, your employer and insurance company expect that you will pay a portion of the cost when you seek medical services. This cost sharing is known as a "patient liability." The following are examples of cost sharing:

  • Co-payment
    Co-payment (co-pay) is a flat payment amount that you are responsible for at the time of service and is usually a nominal fee paid toward the expense of getting care. Typically, co-pays are collected for physician visits, eye exams, pharmaceuticals, emergency room visits, and some diagnostic tests. They often range from $25-$75 for an office visit and up to several hundred dollars for an emergency room visit. This amount is paid each time you obtain a particular medical service. Pharmacy co-pays are often described as "two-tier" or "three-tier," meaning you pay a different amount depending on whether you get a generic or brand-name drug.
  • Deductible
    A deductible is the amount you owe for health care services you receive during the year. If your deductible is $500, you will need to pay $500 before the insurance company pays anything (an exception to this is if a service is covered on a "first dollar" basis, such as preventive care services, which are most often required to be paid in full by your insurance company). Your health insurance company will not pay for anything for your health care until you have paid your deductible. What you pay toward your deductible is tracked from the first day of your cost-sharing year. If the deductible tracking starts January 1, nothing that you have paid prior to January 1 counts toward the $500 deductible. The amount you pay for the deductible does not reduce what you may owe for co-insurance or co-pays.
  • Co-insurance
    Co-insurance is the percentage of the amount paid to a health care provider that you are responsible for. For example, if your co-insurance is 20%, you are responsible for paying 20% of the total amount for the health care services (based on the negotiated rate), and your insurance company will pay the remaining 80%.

Almost all plans have a maximum out of pocket whether it is a plan for an individual (cannot be more than $6,850) or a family plan (cannot be more than $13,700).  There are still some plans that have been allowed to remain available that do not comply with this rule, you should check the details of your plan to find out your maximum out of pocket.