Welcome to Better Health Plan! We know that health insurance can sometimes feel a bit confusing, with lots of terms like "deductible" and "coinsurance." Our goal is to make things as clear and simple as possible so you can feel confident and in control of your health care.
Think of your health plan as a team effort between you and Better Health Plan. You'll share some of the costs for your care, and we'll handle the rest. The terms below explain exactly how that cost-sharing works.
Deductible: The "Starting Line"
Your deductible is the amount you pay out-of-pocket for covered medical services before Better Health Plan begins to pay its share.
- Think of it like this: Imagine your health plan is a big sports game. Your deductible is the first few points you score on your own before the whole team (Better Health Plan) starts to help out.
- How it works: Let's say your deductible is $1,000. You will pay 100% of the costs for most covered services (like doctor visits, lab tests, or X-rays) until the total amount you've paid reaches $1,000. Once you've paid that amount, you've "met" your deductible.
- Important note: Many preventive services, like your annual physical, flu shots, and certain screenings, are covered at 100% before you even meet your deductible!
Copay: The "Flat Fee"
A copay (or copayment) is a fixed amount you pay for a covered service, usually at the time you receive the care.
- Think of it like this: A copay is a set price, like a movie ticket. You pay the same flat fee no matter what the movie is.
- How it works: Your plan might have a $25 copay for a primary care doctor visit or a $50 copay for a visit to a specialist. You pay this amount directly to the provider at the time of your appointment. For many plans, copays do not count toward your deductible, but they do count toward your out-of-pocket maximum.
- An item to note is that some services fall outside of the copay. Those would be subject to coinsurance, which we will discuss next.
Coinsurance: The "Shared Percentage"
Coinsurance is your share of the costs for a covered service, shown as a percentage, after you've met your deductible.
- Think of it like this: Once you've met your deductible, you and Better Health Plan become partners, splitting the costs.
- How it works: Let's say you've met your $1,000 deductible, and your plan's coinsurance is 20%. If you have a covered service that costs $100, you will be responsible for 20% of that cost ($20), and Better Health Plan will pay the remaining 80% ($80).
Out-of-Pocket Maximum: The "Safety Net"
Your out-of-pocket maximum is the most you will have to pay for covered services in a plan year.
- Think of it like this: This is the ultimate financial safety net. It's a cap on your spending, so you never have to worry about overwhelming medical bills.
- How it works: Once the money you've spent on your deductible, copays, and coinsurance reaches your out-of-pocket maximum, Better Health Plan will pay 100% of the cost for all your covered services for the rest of the plan year. This means you won't have to pay any more copays or coinsurance for the remainder of the year.
We hope this helps you understand your benefits a little better. If you ever have questions about a bill or a service, please don't hesitate to contact us!