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Health Insurance Costs
Once you understand health insurance costs and how they all work together, you'll be able to find the right plan to fit your budget. We'll also look at ways you might be able to get help paying for them.
The premium is the amount you (or your employer) pay for your health insurance plan whether you use medical services or not. In most cases, it's paid monthly, but can be paid every 3 months or yearly.
A deductible is the amount you must pay before the health plan starts paying for your covered services. For example, if your deductible is $1,000, your plan won't pay for some services until you've paid $1,000. In most cases, the higher your deductible, the lower your premium. The lower the deductible, the higher premium.
Tip for choosing your premium and deductible
If you know you'll be using your insurance often, you may want to choose a plan with a higher premium and lower deductible. This means you'll pay more each month, but the amount you pay when you go to the doctor will be less over the course of the year.
This also works the other way. If you know you won't use your insurance often, you may want to choose a plan with a lower monthly premium and higher deductible. This way you keep your monthly costs lower by taking the chance that you may not need to pay your deductible.
Coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.
For example, let's say it costs $100 to see your doctor. If your coinsurance is 20%, you must pay $20 and the insurance plan pays $80. If you haven't met your deductible, you must pay the entire amount.
A copayment is a fixed dollar amount you may have to pay at the time you get care. In most cases, it's a small amount, such as $20 for a doctor's exam. You won't always have to pay copayments. The amount you pay depends on your health plan and which doctor you see.
Also called OOPM, this is the most you have to pay out of your own pocket for expenses under your insurance plan during the year. Deductibles, coinsurance, copays and other expenses for in-network essential health benefits (EHBs) apply to the OOPM.
Under the Affordable Care Act, you may be able to get help paying for your health insurance through one or both of these options:
- Premium tax credit — A credit that lowers your monthly premium.
- Cost sharing assistance — A discount that lowers the amount you pay for your deductible, coinsurance and copayments.
To get help:
- Your income must be within a certain range for your household size.
- You can't be claimed as a dependent on someone else's tax return.
- You can't be eligible for a government-sponsored program or an employer-sponsored health insurance plan.
- You must buy a plan on the Health Insurance Marketplace from the Silver plan category.
Low or no-cost health insurance through a government program
Based on your income and family size, you may be able to get low or no-cost health insurance through a government program, such as Medicaid or the Children's Health Insurance Program (CHIP).
You can apply online and if you qualify for Medicaid or CHIP, the proper government office will contact you.
Please note: If you sign up for Medicare or CHIP, you will not be able to use the premium tax credit or cost sharing discount. If you have Medicaid coverage now, you're considered covered under the health care law and don't have to buy a plan on the Marketplace.
You may qualify for Medicaid or CHIP now.
For Medicaid, visit Medicaid.gov .
For CHIP, visit insurekidsnow.gov or call 1-877-543-7669.