Three of the most essential aspects of your healthcare plan are your copay, your coinsurance, and your deductible. But what exactly are these? And how do they work together for your plan? We will look at these terms and explain their meanings as well as how they affect your plan’s cost of care.
Deductibles
According to HealthCare.gov, a deductible is what you pay prior to the amount that your insurance plan pays. For example, if your plan’s annual deductible is $2,000, you will pay this amount before your insurance plan begins to pay for covered health services. After you have met your deductible, you will usually only be required to pay a copay or a coinsurance for services covered by your plan.
Some companies offer very high deductible plans. When reviewing plan options and deductibles, be sure to consider your financial situation and what you would be able to comfortably pay each year towards your healthcare.
Copays
A copay is an amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, emergency room visit, or a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug. Copays must be paid at the time you receive healthcare services. Copays do not apply to your deductible costs, and the amount is established by the insurance plan. It is imperative that you review and consider the copay amount when choosing your health plan.
Why are copays used? Insurance companies have agreements with providers stating they can pay fixed amounts for certain benefits, which allows members to more easily predict costs. Health Maintenance Organization (otherwise known as HMO) plans provide healthcare services through a provider network and are mostly associated with a copay system.
How to Find Information on Your Copays
Some copay amounts are listed on your Member ID card. All copays are listed in your plan documents. However, it is important to note that these copays are usually reserved for in-network providers. If you choose to utilize services from out-of-network providers, then you could have higher copays or a coinsurance, increased out-of-pocket expenses, and reduced or no coverage.
Typically, plans with lower monthly premiums will have higher deductibles while plans with higher monthly premiums will have lower or no deductibles. With either plan type, once you have reached your deductible, you will likely only be required to pay copays or coinsurances for certain health services.
Coinsurances
A coinsurance is a percentage of health care costs that you pay after you have met your deductible. A commonly used coinsurance plan is the “80/20” split. This means that you (the insured) cover 20% of any healthcare costs you may incur, and the healthcare company (the insurer) will cover the other 80%.
For example: a 20% coinsurance for a $100 covered service means that you would pay $20 and your insurance company would pay the remaining $80. Coinsurance may apply for higher cost services as well. For example, a member with a 20% coinsurance would pay $1,200 if the covered service cost $6,000. Coinsurance only applies after you have met your deductible. If you have not yet met your deductible, you would owe the full $6,000 for the covered service in the example above.
If you are a Vantage member wanting details on your plan’s deductible, copay, or coinsurance, you can visit Vantage’s Member Portal or call our Member Services team at 888-823-1910.
