Which is the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid quizlet?

5 Things to Consider When Choosing Your Health Coverage

Choosing a health insurance plan can feel like an overwhelming task. Here are five things to keep in mind when choosing health coverage for you and your family. For specific information on plan components, see your plan’s Summary of Benefits and Coverage (available from an insurance company), call the insurer directly or visit the insurer’s website.

1. Type of Plan and Provider Network

Do the health care providers, hospitals and pharmacies you prefer fall within the plan’s network?

It’s important to remember that in-netword services and medicines are covered under a plan, while out-of-network services and medicines may require additional out-of-pocket costs or may not be covered at all. Importantly, out-of-pocket costs for out-of-network services may not count toward a plan’s out-of-pocket maximum. Check to see if your preferred primary care or specialist provider and the pharmacy near your home are included in the plan’s network.

2. Premiums

How much will you pay per month for coverage?

Premiums are the amount you pay an insurance company for coverage, whether or not you use medical and pharmacy services. Premiums are usually paid monthly, and if you stop making payments, you are at risk of losing your coverage. Keep in mind that these are not the only costs associated with coverage. You will also be responsible for paying deductibles and for cost sharing, for example, co-pays and coinsurance, for most health care services and treatments. (See descriptions below)

3. Deductibles

What is the amount you must pay out of pocket before your coverage kicks in?

For example, if your deductible is $1,000, your health plan won’t pay most expenses until you’ve spent $1,000 on expenses out of pocket. Out-of-pocket costs may include specialist visits, procedure fees, and in some cases even prescriptions. Certain preventive services, such as approved cancer screenings and vaccines, are typically covered with no cost sharing before you reach your deductible. Patients who select a plan with a high deductibles will most likely have a lower monthly premium, while lower deductibles often have higher monthly premiums. Insurers increasingly require a deductible to be met before covering most medical or pharmacy services. Be sure to check with your insurer to know if your plan has either a single, combined deductible for medical and pharmacy services or a separate deductible for prescriptions to know how much you’ll have to pay before medicines are covered.

4. Co-pay or Coinsurance

Are you aware of other costs that you may be required to pay to access care?

Don’t forget you may be responsible for other out-of-pocket expenses even after you reach your deductible. These can include:

• Coinsurance - a percentage of costs you must pay for a medicine or service, or

• Co-pay - flat fees you are required to pay for prescriptions or covered services (often listed on the back of your insurance card)

5. Coverage of Medicines

Are your regular prescriptions covered by your insurance plan?

Each insurer has a formulary (list of medicines) covered by the plan. If a medicine is not on the formulary, it may not be covered, and patients will then have to go through a potentially lengthy process to obtain coverage. The list of covered medicines is also divided into tiers, which determine how much of a co-pay or coinsurance you may have to pay. Make a list of your current medicines, and compare it to the plan’s formulary to make sure your medicines are covered and you understand the out-of-pocket costs that may be associated with them.

The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.

Related Content

• Getting lower costs: How to save on out-of-pocket health care costs
• How to choose Marketplace insurance: Out-of-pocket costs

Plans in the Marketplace are presented in 4 health plan categories: Bronze, Silver, Gold, and Platinum. (“Catastrophic” plans are also available to some people.)

FYI Health plan categories are based on how you and your plan split the costs of your health care. They have nothing to do with quality of care.

How you and your insurance plan split costs

Which health plan category is right for you?

Bronze

• Lowest monthly premium
• Highest costs when you need care
• Bronze plan deductibles — the amount of medical costs you pay yourself before your insurance plan starts to pay — can be thousands of dollars a year.
• Good choice if: You want a low-cost way to protect yourself from worst-case medical scenarios, like serious sickness or injury. Your monthly premium will be low, but you’ll have to pay for most routine care yourself.

Silver

• Moderate monthly premium
• Moderate costs when you need care
• Silver deductibles — the costs you pay yourself before your plan pays anything — are usually lower than those of Bronze plans.

• Good choice if: You qualify for “extra savings” — or, if not, if you’re willing to pay a slightly higher monthly premium than Bronze to have more of your routine care covered.

Gold

• High monthly premium
• Low costs when you need care
• Deductibles — the amount of medical costs you pay yourself before your plan pays — are usually low.
• Good choice if: You’re willing to pay more each month to have more costs covered when you get medical treatment. If you use a lot of care, a Gold plan could be a good value.

Platinum

• Highest monthly premium
• Lowest costs when you get care
• Deductibles are very low, meaning your plan starts paying its share earlier than for other categories of plans.
• Good choice if: You usually use a lot of care and are willing to pay a high monthly premium, knowing nearly all other costs will be covered.

Find out how to use total costs of care to pick a category and plan that work for you.

Note: Plans in all categories provide free preventive care, and some offer selected free or discounted services before you meet your deductible.

Your premium can be lower, based on your income

No matter which health plan category you choose, you can save a lot of money on your monthly premium based on your income.

When you fill out a Marketplace insurance application, you’ll find out if you qualify for these savings. Learn how you can save on your monthly insurance bill with a premium tax credit.

You can do a quick check now to see if your income’s in the range to qualify.

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