6 things to know about deductibles in the Health Insurance Marketplace

Deductibles, premiums, copayments, and coinsurance, are important for you to consider when choosing a health insurance plan. You can compare health plans and see if you qualify for lower costs before you apply. Most people who apply will be eligible for help paying for health coverage.

Here are 6 important things to know about deductibles:

  1. Having health insurance can lower your costs even when you have to pay out of pocket to meet your deductible. Insurance companies negotiate their rates with providers and you’ll pay that discounted rate. People without insurance pay, on average, twice as much for care.
  2. A health insurance deductible is different from other types of deductibles. Unlike auto, renters, or homeowners insurance, where you don’t get services until you pay your deductible, many health insurance plans provide some benefits before you meet the deductible.
  3. All Marketplace plans cover preventive care. Screenings, immunizations, and other preventive services are covered without requiring you to pay your deductible. Many health insurance plans also cover other benefits like doctor visits and prescription drugs even if you haven’t met your deductible.
  4. In 2014, there’s a $6,350 maximum for individual out-of-pocket costs for in-network services.The maximum for families is $12,700. Even if you choose a high deductible catastrophic plan, your out-of-pocket costs should not exceed this limit.
  5. Over 70% of Marketplace plans have deductibles under $3,000. When you choose a health insurance plan, it’s important to understand what your insurance company covers without requiring you to pay your deductible. Then you can decide whether you want a plan with lower monthly premiums and a higher deductible, or one with a higher monthly premium and a lower deductible.
  6. Silver plans can save you more. If you qualify for lower out-of-pocket costs and choose a Silver plan, you can save more with a lower copay and a lower deductible. If you qualify, you’ll get the out-of-pocket savings benefits of a Gold or Platinum plan for a Silver plan price. You can choose any category of plan, but these out-of-pocket savings apply only if you enroll in a Silver plan.

How do deductibles, coinsurance and copays work?

Who is this for?

This information will help you if you’re shopping for health insurance and have questions about how it works.

When both you and your health insurance company pay part of your medical expense, it’s called cost sharing. Deductibles, coinsurance and copays are all examples. Understanding how they work will help you know when and how much you have to pay for care.

Deductible

  • A deductible is the amount you pay for health care services before your health insurance begins to pay.

Let’s say your plan’s deductible is $1,500. That means for most services, you’ll pay 100 percent of your medical and pharmacy bills until the amount you pay reaches $1,500. After that, you share the cost with your plan by paying coinsurance and copays.

Coinsurance

  • Coinsurance is your share of the costs of a health care service. It’s usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you’ve paid your plan’s deductible.

Here’s how it works. Lisa has allergies, so she sees a doctor regularly. She just paid her $1,500 deductible. Now her plan will cover 70 percent of the cost of her allergy shots. Lisa pays the other 30 percent; that’s her coinsurance. If her treatment costs $150, her plan will pay $105 and she’ll pay $45.

If Lisa has a PPO plan, she has the option to see any doctor she wants. If she goes to an out-of-network doctor, her plan will still share the cost, but her percentage of coinsurance will be higher. And, if the medical service she gets is more than what her plan would pay for an in-network doctor, she’ll have to pay the difference.

Learn more about the difference between in-network and out-of-network benefits.

Copay

  • A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.

For example, a doctor’s office visit might have a copay of $30. The copay for an emergency room visit will usually cost more, such as $250. For some services, you may have both a copay and coinsurance.

What does this mean for me?

When choosing a plan, think about how much you use your insurance and how much protection you want against unpredictable expenses. Then look at the plan’s deductible, coinsurance and copays and find what works best for you. Here are a few things to consider.

  • Deductible: A plan with a high deductible will have cheaper monthly payments. But you’ll pay a lot upfront when you need care. You can also look for plans that cover some services before you pay your deductible.
  • Coinsurance: Typically, the lower a plan’s monthly payments, the more you’ll pay in coinsurance.
  • Copays: If you visit your doctor or pharmacy often, you might want to choose a plan that has a low copay for office visits and prescriptions.