Most of the time, you will pay something when you receive medical care. When you and you insurance company each pay part of the cost, it is known as “Cost Sharing”. There are a number of different types of cost sharing, and sometimes you’ll pay more than one for a particular service:
The deductible is the amount you will pay each year (or policy period) for most health care services before your insurance company begins to share the costs.
For example, if your deductible is $500, you will pay the full network cost of your care until you have paid out $500. Then, for the rest of the year (policy period) you and the plan will share the cost.
You don’t have to pay a deductible before your plan covers preventive care. And, depending on your plan, other care may be covered before you meet your deductible (such as in-network primary care provider visits or prescription drugs which might require only a co-payment). Check your summary plan description or plan booklet for information about what your deductible applies to.
The deductible applies every year; so, next year (or policy period) it starts all over again.
A co-payment is a flat dollar amount that you pay at the time of service. Typically, co-payments are collected for physician visits, eye exams, prescription drugs, emergency room visits, and some diagnostic tests. You may or may not have to pay your deductible for services that require a co-payment.
Co-payments often range from $25-$75 for an office visit, up to a few hundred dollars for an emergency room visit. They are paid each time you receive a particular medical service. Pharmacy co-payments often vary depending on your plan’s drug list (learn more ).
Co-insurance is a percentage of the amount paid to a health care provider. For example, your insurance company may pay 80% and you will pay the remaining 20%. Co-insurance may be combined with the deductible and even a co-payment, depending on the service and your plan.
Reminder: in-network preventative services are not subject to cost-sharing.
Learn more about how deductibles, co-payments and co-insurance are determined.
Use the Health Costs section of this site to compare costs at various providers/facilities and under different health plans. This can help you estimate how much you might pay for your care.
Almost all plans have a limit on the amount you will have to pay for most services each year (policy period) called the out-of-pocket maximum (learn more).