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Here’s an example of how insurance works:

Let’s say you develop a serious illness, need surgery, and a hospital stay. The costs of your covered medical expenses add up to $50,000.

Without health insurance, you would be responsible for paying all $50,000. That’s a big financial hit! But with insurance, your financial responsibility is much smaller.

For this example, we’ll say these are the terms of your health insurance:

  • Your deductible is $5,000.
  • Your coinsurance is 20%.
  • Your maximum out-of-pocket is $7,000.

In this case, you are responsible for the first $5,000 in charges. This is your deductible. After you’ve paid your deductible, there are $45,000 of expenses left. You are responsible for 20% coinsurance – that is 20% of the remaining cost, or $9,000. This is more than your maximum out-of-pocket of $7,000. So you pay $5,000 toward the deductible and only $2,000 of the coinsurance.Your insurance plan pays the rest of the covered expenses.

Here’s how it breaks out: 

  • Your payments come to $7,000.
  • Your health insurance pays $43,000.

In addition, since you’ve reached your maximum out-of-pocket limit for the year, you won’t have to pay anything for the rest of the year for covered medical expenses.

Here are several of the most common terms you’ll come across. Becoming familiar with them will make it easier to understand the details and total cost of the plan:

Benefits.

Benefits are payments the plan makes to cover all or part of covered medical expenses. They vary according to the plan you choose and usually include a portion of the cost of doctors’ visits, prescription medicine, hospital charges, ER visits, and more.

Premiums.

These are the payments you make for your insurance. How do insurance companies figure out what your premium will be? Rates are affected by many things, including the cost of the various medical services they will cover and how likely their policyholders, or customers, are to need those services.

The Affordable Care Act introduced some changes in how premiums may be set: A premium can be based on your age (older adults can’t be charged more than three times what a younger person is charged), geography (insurers can charge more in areas where medical costs are high), family size (an individual versus an individual plus a spouse and/or children) and tobacco use (those using tobacco products can’t be charged more than 1.5 times what a non-tobacco user is charged). You can’t, however, be charged a higher premium based on your gender or if you’re sick or have a history of health problems.

Deductible.

This is the amount you’re responsible to pay for covered medical expenses (the medical services that are covered under your plan) before your insurance begins to pay each year. When you hear that someone has “met their deductible,” it means they have paid their part of their healthcare costs. Their plan will begin to pay its portion for healthcare costs; however, you may still have to pay a co-pay or a percentage of the cost of care, called coinsurance. Typically, anything you pay out of your own pocket, except for premiums, co-pays and some prescription drug costs, will go toward meeting your deductible.

Co-pays.
Some plans include co-pays. These are set prices for various services you may need. For example, you may pay a $20 co-pay for a visit to your primary care physician, or a $100 co-pay for a visit to the emergency room.

Coinsurance.

Coinsurance means the costs of covered medical services are shared between you and your insurance company after the deductible has been met. For example, if a plan has 80/20 coinsurance, the plan would pay 80 percent of a covered medical expense, while you would pay 20 percent of the same covered medical expense.

Maximum Out-of-Pocket.

This is the most money you will be required to pay in a year for deductibles, co-insurance and co-payments. It is a specific dollar amount that is part of the health insurance plan. After you’ve reached that amount, the insurance company may cover the cost of the rest of your covered medical expenses.

Claims.

After you have a medical service, the doctor or facility that provided that service will file a claim with your insurance company. A claim is a formal request asking for payment based on the terms of the insurance plan. Your insurance company will review the claim to make sure it is valid. If so, the appropriate amount will be paid out to the insured person or to the doctor or facility that filed the claim.

– Humana Health Insurance Basics

 

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