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Medical Offices of Manhattan
Understanding Deductibles & Other Health Insurance Terms

Trying to understand your health insurance plan can feel like navigating a maze. It isn’t always entirely clear which providers are eligible for insurance coverage, which procedures are covered under your plan, or how to get the most useful, cost-effective care. If you’re unfamiliar with the vocabulary that health insurance companies use, it can be especially difficult to understand the specifics of how to make your plan work best for you.

However, it’s important to try and get to know the ins and outs of your coverage and make sure that you select the best available plan for your situation. Not only will this save you from spending more money than you need to or getting hit with unwelcome surprises on your healthcare bills, it can also spare you from the headaches or wasted time that can result from needless back and forth with your insurance carrier. We’re here to help! Here’s a quick overview of some of the key terms relating to health insurance.

What is a Deductible?

One number that may vary a great deal from one plan to another is the deductible. This is the amount of money that you may have to pay 100% out of pocket over the course of one year before covered healthcare is paid for by your insurance company. In most cases, copayments or coinsurance costs will not count toward your deductible, and preventive doctor visits such as regular PCP check-ups or vaccination appointments are usually covered whether the deductible has been reached or not.

Because the amount of out-of-pocket money spent towards your deductible resets at the start of each year, the best plan for you generally depends on how much healthcare you are likely to receive over the course of twelve months. Higher-tiered “platinum” or “gold” plans will typically have lower deductibles (some even have no deductible) than the “bronze” or “silver” offerings, but will also have a comparatively higher monthly premium. 

This means that people who require frequent doctor visits or multiple regular prescriptions may want to choose a plan with a lower deductible, while individuals with fewer care requirements who are less likely to reach their deductible over the course of a year might opt for a plan with a higher deductible and lower premium.

What is an Out of Pocket Maximum?

This one may seem a little more self-explanatory. In addition to a deductible, some plans will have a separate, higher number which places a maximum amount that you can spend out of pocket during one year. After your out of pocket maximum is reached, one hundred percent of medical costs will be paid for by your insurance provider. Some packages are “no cost after deductible” plans, in which the deductible itself represents the out of pocket limit.

What is a Copayment?

A copay is the set amount of money that you will be required to pay for various services which are covered under your health insurance. Copayments will vary from plan to plan and service to service – for instance, a normal visit to your primary care provider may have a different copay than an urgent care visit or mental healthcare appointment, etc.

What is Coinsurance?

Once your deductible has kicked in, your coinsurance determines the percentage of your healthcare costs that will be shared between you and your insurance provider. So, if your coinsurance is 20%, you’ll be required to cover 20% of costs while your insurance carrier takes care of the other 80%, from the point the deductible is reached up to your out of pocket maximum. A no cost after deductible plan will show 0% under coinsurance.

Feeling Lost? Don’t Be Afraid to Ask Questions

When it comes down to it, everybody deserves to get the healthcare they need without having to worry about what to expect on their bill. We want all of our patients to feel confident and comfortable with their healthcare experience. If you have any questions about using your insurance for an appointment with Medical Offices of Manhattan, please feel free to contact our office.