Health insurance plans come in all shapes and sizes, so it’s important for you to understand how your specific plan works. As many plans have changed significantly in the past few years, you should be aware that your plan may not cover your health needs the way it always used to. Contact your health insurer for a clear understanding of your benefits.

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Insurers negotiate rates with different healthcare organizations and providers, which could impact the cost of care at those locations. Typically, visiting a provider that is in your plan’s network will cost less than a provider what is out-of-network. Your insurance company can tell you if the doctor or facility you wish to visit is in your plan’s network.

What is a deductible?

A deductible is the amount you pay for eligible medical services or medications before your insurance plan kicks in. For example, if you have a $5,000 annual deductible, you are responsible for $5,000 in medical expenses before your insurance plan begins to pay its contracted rate.

Many plans are now considered “high-deductible plans.” These plans come with a lower monthly premium, but they make the consumer responsible for a larger share of medical costs when those costs are incurred.

What is a copay?

A copay is the flat fee that you pay for a medical visit or prescription. For example, if you visit your doctor for an unexpected health need (e.g., a sprained ankle) and your co-pay is $50, you will pay $50 for that visit.

Copays are typically printed on your insurance card, so check there first. Copays may not count toward your plan’s deductible.

What is coinsurance?

Coinsurance is the amount you pay for medical services once your plan begins coverage – typically after you’ve met your deductible. For example, if you have met your deductible and visit the emergency room for a broken leg, your insurance may pay 80 percent of the fees, and you will be responsible for the remaining 20 percent.

Most plans have an “out-of-pocket maximum” – which is the total amount that you can pay in a year for your medical expenses and prescriptions. Once you have reached that amount, most plans will pay 100 percent of your health costs.

Do you know how your plan works?

To learn the answers to these questions, call your insurer. They will help you understand how your specific plan works and identify the nearest care locations or providers that are covered by your plan.

  • What is my deductible?
  • Do I have any copays? If so, for what type of visits and how much are they?
  • What is my out-of-pocket maximum?
  • Are my current providers “in-network” (e.g., covered by this plan)?
  • What is the preferred urgent care and emergency room location for me and my family?

If you are experiencing an emergency, call 9-1-1.