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Deductibles, Coinsurance, Copays


It's the beginning of the new year, and we all know what that means. New Health Plan Deductibles! I know I know, but in the health insurance world, January 1 is whenever the calendar year deductible resets.


Some of us may not even know what a healthcare deductible is. Well, a deductible is defined as the amount of money you pay for health care services before the insurance starts to pitch in. Let's say you have a health insurance plan with a deductible of $1,500. You would be responsible for paying all of the upfront charges for claims and services until you reach the $1,500 threshold. Then your insurance company is going to start paying the coinsurance costs share.


That digs us into another definition that I want to discuss, and that's coinsurance. The coinsurance is the amount of shared costs between you and your insurance provider for covered health care services. After you reach your deductible. If you have a $1,500 health plan, and you have reached the $1,500 deductible limit, then your health insurance may have a cost share split of 7030, or 8020, which means the insurance is going to pay for the majority of that claim dollar, but you'll be responsible for a small portion, which you'll get billed after the claim is processed through the insurance provider.


There are some types of services that you don't have to worry about reaching the deductible or the coinsurance in order to be treated by your provider. Some of those services are preventive care, as defined by the Affordable Care Act, as well as some defined services such as doctor's visits, labs and x-rays, or maybe even specialist visits. Those copays will all be defined in your plan description and relayed to you every year during open enrollment. Usually, a copay could be $0 for going to your primary care practitioner or using a telehealth or telemedicine service. Perhaps you want to go see a specialist and they charge you a $50 or $75 upfront copay for that service. That way, you don't have to worry about reaching your deductible or having any coinsurance or costs you're splitting.


I hope this information was valuable for you. My name is Niki Trentacosta and I help employers shop for and administer employee benefits for their teams. I love working with small business owners as it helps me be able to educate the owner and the employees on the best needs to fit their small businesses. I'd love to talk to you or your employees about a health care program. I can be reached at thetanangroup.com and on social media platforms such as Facebook, YouTube, LinkedIn, and Twitter. I look forward to talking to you about your group's employee benefits needs. And until we do speak, I hope that you stay happy, stay healthy. And of course, be sure to wash your hands. Bye!


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