Health Care Costs
Coinsurance and other out-of-pocket costs can affect your health insurance costs. Here are some typical scenarios that may help you better understand these potential costs.
Here's an example:
Let's say you've met your annual deductible, so your plan now provides benefits for covered services. You may wonder what you will have to pay if you visit your doctor or other health care provider. The answer depends on the percentage your plan pays for covered medical services after your deductible is met.
For example, you bruise your hip in a fall and you need an X-ray. If your plan covers 80 percent of an X-ray, here's how the costs might break down:
The X-ray costs are $200.
Your plan covers 80 percent, which is $160.
Your coinsurance, 20 percent is $40 for the X-ray.
You should also know about the maximum limit (sometimes called "allowable amount" or "eligible charge") for a procedure or medical service based on your plan. This is the most your plan will pay for a particular service. These set amounts help manage overall rates.
Let's say your doctor or other health care provider charges more for an X-ray than your plan's maximum limit*:
Your plan pays up to $150 for an X-ray.
Your doctor or other health care provider charges $200.
You may be responsible for the $50 difference.
So, when calculating the amount you will have to pay (often referred to as your out-of-pocket costs), two things to keep in mind are:
The percentage that is covered by your plan.
The limit for any specific service you'll be using.
But what if you haven't met your annual deductible and your child breaks her arm?
In this example, we'll assume you take her to the emergency room. After X-rays, diagnosis, casting and more, the total bill is $2,400. Your plan covers 80 percent of emergency room services after a $75 copayment. Plus you have a $500 family deductible to fulfill.
You are responsible for the first $500, which is your deductible, plus the $75 copayment.
That leaves a balance of $1,825.
Your plan will pay 80 percent of the doctor's or other health care provider's contracted allowable amount, which is $1,460.
You are responsible for 20 percent of the doctor's or other health care provider's contracted allowable amount, which is $365. Your total out-of-pocket cost for this incident will be $940.
In this scenario you will have met your annual deductible and any future medical services during that year will be reimbursed based on your plan's benefit design until your out-of-pocket maximum is met or until the new benefit period begins. In the above example, if you had already fulfilled your annual deductible, your cost would have been only $540
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.