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In this section, you’ll find a list of commonly asked questions and our responses. If you don’t find the information you’re looking for, please don’t hesitate to contact us directly. We’re always happy to assist you in any way we can.

What is a Deductible versus Co-Insurance versus Copay?

We get it! Insurance can be confusing. Here is a list of standard insurance terms with brief descriptions to help understand your policy a little more.

  • Premium: This is the amount you pay for your health insurance coverage. A premium is paid to an insurance company in exchange for their services and coverage. It can be paid monthly, quarterly, or yearly, depending on the insurance company’s requirements. A premium is separate from deductible, co-insurance or copayment amounts due for rendered care.
  • Deductible: This is the amount you pay annually for healthcare services before your insurance company will pay its share. For example, if you have a $1,500 deductible for your plan, your insurance may not start to cover their share of your healthcare claims until you’ve paid $1,500. Most plans still cover the cost of preventive care visits before you have met your deductible for the year (for example – Annual Wellness Visits).
  • Co-Insurance: After your deductible amount is met for the year, most health insurance plans require you to cover a percentage of your care costs. This percentage is called your co-insurance amount and is specific to your individual health insurance plan. For example, if you have a 20% co-insurance amount per your plan, that means for every $100 owed for your healthcare, you will pay $20 and your insurance will pay $80.
  • Copayment (Copay): This is the amount you owe each time you receive certain types of medical care. They are specific to your individual health insurance plan and may vary depending on the kind of service – for example, you may have a $30 copay to see your Primary Care Provider, but a $50 copay to see a specialist.
  • Out-of-Pocket Maximum: This is the maximum amount you will pay each year towards your healthcare, including your deductible amount, copays, and co-insurance amounts. Once you have reached your out-of-pocket maximum for the year, your insurance company should pay for the remainder of your care within that year. It is important you know the specific details for your plan. Some plans do not count extra services like acupuncture or hearing aids, or visits with Out-Of-Network providers towards your out-of-pocket maximum.
  • Preauthorization: Some insurance plans require preauthorization for certain services before you receive them. Know the specifics of your plan! If this is something your plan requires, and preauthorization is not obtain prior to receiving the services, your insurance will likely not cover the charges unless it is part of emergency care.
  • Health Savings Account (HSA): This is a special account that individuals can open at a bank or credit union to deposit pre-tax dollars to be used towards their medical expenses. HSA funds remain in your account until you use them. An HSA is different than a Flexible Spending Account (FSA). FSA’s follow the same concept where pre-tax dollars are held, but they are connected to your job. FSA funds must be used up before the end of the year, as they do not roll over.
  • Network: An insurance network is a group of healthcare providers contracted with an insurance company to provide discounted services. They are typically made up of general physicians, as well as specialists such as dermatologists, chiropractors, oncologists, cardiologists, etc. Networks may also include laboratories. It is very important to confirm with your insurance company that the provider(s) you wish to see are In-Network or Out-of-Network with your specific plan, as this can severely impact whether or not your insurance will cover the care rendered.
    1. In-Network: An In-Network provider is a provider that has contracted with your insurance company.
    2. Out-Of-Network: An Out-of-Network provider is a provider that has not contracted with your insurance company.
  • Health Maintenance Organization (HMO): HMOs are a type of managed care plan offered by most insurance companies. Most HMO’s typically have lower premiums and out-of-pocket maximums. However, HMO’s restrict members to a particular group of physicians, and will not cover your care if you see an Out-of-Network provider. If you have an HMO, you must always see your Primary Care Provider (PCP) first. If your PCP is unable to treat the problem, they can refer you to an In-Network specialist.
  • Preferred Provider Organization (PPO): PPOs are a type of managed care plan offered by most insurance companies. Most PPO’s have higher premiums and out-of-pocket maximums. However, PPO’s come with more flexibility and allow members to select any physician they desire. If you have a PPO, your plan typically doesn’t require you to select a Primary Care Provider (PCP). You are generally free to see a specialist without a referral by a PCP. You are also free to see both In-Network and Out-of-Network providers. Your plan will cover more of the cost if you remain In-Network, but still offers some coverage if you go Out-of-Network.

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