Co-pay. Think of the co-pay as the admission fee for access to a provider. This is the amount the patient pays “up front” at the doctor’s office, hospital ER, or when filling a prescription. The co-pay is kept by the provider as part of their payment for providing the service. The co-pay does not count toward the deductible.
Deductible. A deductible is the amount that a patient is responsible for before the insurance plan accepts responsibility for its share of payments to providers. Deductibles commonly range from $500 to $2,500 or more.
Coinsurance. After the deductible has been met, this is the percentage that the plan pays of the balance. Many plans apply a deductible and coinsurance, usually 70%, 80%, or 90%, to all services. Some plans, like the standard PPO that the UUA offers, cover some services at 100%, often without a deductible. This is an area where you have to read your coverage documents.
Out-of-pocket Maximums. Most plans, but not all, limit your financial exposure in a calendar year. The UUA standard PPO, for example, limits your exposure to $5,000 per individual, and $10,000 per family. These limits to a subscriber’s financial exposure are often overlooked. Some commercial plans can offer low premiums because the patients assume a very large risk for catastrophic care. (In the insurance world, the word “catastrophic” refers not to the disease but to the high cost of treatment.)
