Understanding your responsibility for medical costs versus your plan’s can help you make the right decision when it’s time to choose your health insurance. Here are the key terms to know.
This is the amount you pay each month for your health plan. If you get your insurance through work, your employer also contributes to the cost.
This is the amount you must spend out of pocket each year before your health insurance company starts paying its share of your medical costs. There are some exceptions, such as preventive care and screenings, which are covered immediately at no cost to you.
This is the amount you pay for certain medical visits. For instance, you may pay a $25 copayment to see a gastroenterologist. That payment is typically due at your appointment. However, you don’t have a copayment for preventive care and screenings.
This is a percentage you pay for certain medical services, even after you’ve reached your deductible. For instance, many plans have a 20% coinsurance for hospitalization. So if the entire bill is $10,000, you pay $2,000. There is no coinsurance for preventive care and screenings.
Maximum Out-Of-Pocket Limit
This is the maximum amount you can pay each year for medical expenses. It includes the deductible, coinsurance and copayments—but not the premium.
In 2024, the maximum out-of-pocket limit is $9,450 for an individual plan and $18,900 for a family plan.
Services Usually Not Covered
These are services your plan doesn’t cover. For instance, some plans don’t pay for investigational treatments. Others won’t cover the cost of out-of-network care, dental care, or eyeglasses. And few plans cover elective procedures like plastic surgery. Bottom line: For these services, you have to cover the entire cost.
Last updated: November 2023