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Understanding Costs

When you shop for health insurance, you have to make your decisions about what to buy based on your financial situation and health care needs.

If you know you will be using your insurance quite often, you may choose to pay a higher premium in exchange for a lower deductible. This means that you'll pay more upfront for your benefits, but the amount you have to come up with out-of-pocket when you go to the doctor over the course of the year will be less.

This also works in reverse. If you know you don't typically have a lot of health care expenses, you may choose to go with a lower premium. Your deductible will be higher, but you are taking the chance that you may not need to spend it all during the year.

Many plans also include copays or coinsurance, which are amounts that you pay directly to your care provider for things like office visits.

Here's an example of how it works for you.

You have an insurance plan that has these basics:

  • $5,000 deductible
  • 20% coinsurance
  • Out-of-pocket maximum of $6,000

Under this plan, you will be responsible for paying for the first $5,000 of your medical costs. After that, your plan covers 80% of the costs, and you pay the remaining 20%. When the amount of coinsurance you've paid reaches $6,000, the plan covers 100% until your "plan year" renews. A plan is good for one year. At the beginning of the next plan year, your deductible and coinsurance resets for the next plan year and the $5,000 deductible and 20% coinsurance will start again.

When buying health insurance, it's important that you know how your plan works so that you are aware of potential costs. Learn about how insurance works and explore typical cost scenarios.

When you're shopping for insurance, the total cost of keeping you and your family healthy is a top concern. You want your plan to cover your total health care costs as much as possible, you want affordable premiums, and you want any out-of-pocket health care costs to be minimal. To help you shop for a plan that meets all of these factors, it's important to understand the costs that go into buying and using health insurance.

  • Selecting coverage through your employer or another group? Use the Health Plan Cost Estimator to evaluate insurance plan options and estimated annual costs.

Your Total Health Insurance Cost and the Network

When you choose a plan, one thing to consider is the size of their network. It's your lifeline to quality and convenient care. A specific network of doctors, hospitals and other health care professionals, sometimes called providers, helps keep your premiums low for a number of reasons:

  • Network doctors and hospitals have agreements with the insurance company that save you money
  • Services are provided at a lower rate to members
  • Streamlined expenses, such as billing, keep costs down
  • Providers are held to certain quality standards for plan members

When you choose care outside a specified network, benefits and costs can change. Every plan is different, however, some plans provide limited coverage and others offer no coverage at all for out-of-network services. Since doctors, hospitals and other health care professionals outside the network don't have an agreement with your insurance company, the price of services may be higher.

When you're shopping for insurance, look closely at the plan network. Check to see if you will be able to get as many services within the network as possible, or that you'll have options, if you decide to go outside the network.

Other Expenses That Affect Your Total Health Insurance Cost

Your total health insurance cost can also be affected by your out-of-pocket expenses. There's the copayment, which is usually a small fixed amount you pay per visit to in-network doctors. That's not to be confused with coinsurance. That's the percentage of costs you may be responsible for within your plan, once you satisfy your deductible.

For example, let's say you've met your annual deductible, so your plan now pays for benefits. You may wonder what you will have to pay if you visit your doctor. The answer depends on the percentage your plan pays for medical services that are covered under the plan.

For example, you bruise your hip in a fall and you need an X-ray. Your plan covers 80 percent of an X-ray. Here's how the costs might break down:

  • The X-ray costs $200
  • Your plan covers 80 percent, which is $160
  • Your out-of-pocket cost, or coinsurance, is $40 for the X-ray

That's a simple example. You should also be aware of the maximum limit for a procedure or medical service specified in your plan. These limits help keep rates to a fair and reasonable standard, which helps lower costs for all members.

To illustrate this, let's say that, for some reason, your doctor charges more for an X-ray:

  • The maximum covered cost for an X-ray in your plan is $200
  • Your doctor charges $300
  • You may be responsible for the $100 difference

So, when calculating your out-of-pocket costs, two things to remember are the percentage that is covered by your plan and the limit for any specific service you'll be using. You also need to consider your out-of-pocket expense limits. The out-of-pocket expense limit represents the maximum amount you are responsible for each year. Once the out-of-pocket expense limit is reached, insurance covers 100 percent of eligible expenses.

When you understand some of the costs of buying and using health insurance, it's easier to find the plan that's best for you and your family. Best of all, you'll be able to get the most out of the plan you choose.


Health Plan Cost Estimator

Use the estimator tool to create a health profile to evaluate insurance plan options and estimated annual costs.

If your employer has given you an eight-character pass code to access your employer group's Health Plan Cost Estimator tool, enter the code below.