A deductible is what you pay annually for health services before your insurance company pays its share. For instance, if you have a deductible of $1,000, your insurance plan might not start covering its share of your bills until you’ve paid $1,000 for healthcare in a given year. This does not mean the services are not covered.
Your copay is the amount you owe each time you receive certain types of medical care.
Depending on your policy these can vary from doctor to doctor. For example, you may have to pay a $30 copay for each visit to your PCP and $60 for each visit to a specialist, like your psychiatrist or cardiologist. Most copays do not count towards your deductible. You will need to find out from your insurance carrier if yours do.
After you’ve met your deductible for the year you may have a coinsurance. That’s the percentage of your medical expenses that you are responsible for. For example, once you meet your $1,000 deductible your coinsurance would be 20% from there on. That means you would pay $20 of a $100 bill and the insurance company would pay the other $80.
This does not mean that the services aren’t covered- just that your insurance carrier is only responsible for a percentage, according to your policy. Some policies do not have a coinsurance, in which case your insurance would cover 100% after your deductible is paid.
Your out-of-pocket-maximum is the most you’ll ever be required to pay each year towards your medical bills. This includes your deductible, copays, and coinsurance.
Say your OOP Max is $5,000. This means that once you have paid $5,000- between your deductible, your copays, and any coinsurance you have- your insurance company will then cover 100% of the costs for any other services until your policy resets at the end of it’s term.
Premiums aren’t included in the out-of-pocket maximum and neither are extra services or equipment such as hearing aids and acupuncture. If your plan distinguishes between in-network and out-of-network providers, out-of-network bills may not count toward your out-of-pocket maximum either, so review your policy carefully.
The allowed amount is the amount that the insurance company has determined to be a fair price for a given medical treatment. If your doctor is part of that health plan's network, then they have agreed to that specific allowed amount, and the provider agrees to write off any charges above that amount.
For instance your doctor may have priced a procedure at $200, but the insurance company has only agreed to pay $75 for that procedure. This means that the provider and insurance will adjust and write off $125, leaving the insurance to only pay your provider $75 for the procedure.
Your health plan may have different allowed amounts for the same service, since their contracts vary from one medical provider to another.
EOB stands for Explanation of Benefits. This is a document sent to you by your insurance to let you know a claim has been processed. The most important thing for you to remember is that an EOB is NOT a bill. It is a document letting you know which healthcare provider has filed a claim on your behalf, what it was for, whether it was approved, and how much your insurance is covering.
You should always review your EOB to make sure it’s correct and contact your insurance’s claims department with any questions.
The ongoing amount that must be paid for your health plan. You and/or your employer usually pay it monthly, quarterly or yearly.
The premium may not be the only amount you pay for insurance coverage. Typically, you will also have a copay or deductible amount.