A policy is a contract between the insurance company and an individual or business owner (Group). The contract can be renewable annually or monthly. The type and amount of services and costs that will be covered by the plan are specified in advance, in the member contract or Evidence of Coverage booklet. The individual policy-holder's payment obligations may take several forms:
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Premium: The amount the policy-holder pays to the plan each month to purchase coverage.
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Deductible: The amount that the policy-holder must pay out-of-pocket before the plan pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take several doctor's visits or prescription refills before the policy-holder reaches the deductible and the plan starts to pay for care.
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Copayment: The amount that the policy-holder must pay out of pocket before the plan pays for a particular visit or service. For example, a policy-holder might pay a $45 copayment for a doctor's visit, or to obtain a prescription. A copayment must be paid each time a particular service is obtained.
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Coinsurance: Instead of paying a fixed amount up front (a copayment), the policy-holder must pay a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the plan pays the other %80. Because there is no upper limit on coinsurance, the policy-holder can end up owing very little, or a significant amount, depending on the actual costs of the services they obtain.
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Exclusions: Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket.
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Coverage limits: Some plans only pay for health care up to a certain dollar amount. The policy-holder may be expected to pay any charges in excess of the plan's maximum payment for a specific service. In addition, some plans have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.
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Out-of-pocket maximums: Similar to coverage limits, except that in this case, the member's payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
Prescription drug plans are a form of insurance offered through many employer benefit plans in the U.S., where the patient pays a copayment and the prescription drug insurance pays the rest.
Some care providers will agree to bill the company if patients are willing to sign an agreement that they will be responsible for the amount that the company doesn't pay, as the company pays according to "reasonable" or "customary" charges, which may be less than the provider's usual fee.
Companies also often have a network of providers who agree to accept the reasonable and customary fee and waive the remainder. It will generally cost the patient less to use an in-network provider.
Some companies are now offering Health Incentive accounts (HIA), to reward users for living healthy and making healthy choices, like stop smoking and/or losing weight, may get you funds added into your Health Incentive Account, which may lower your out of pocket costs. The health incentive accounts also carry over from year to year but once you leave the program you lose those benefits in the HIA.
Please Note; the previous information is provided for general informational purposes only and is not intended to be construed as advice, recommendations, suggestions or consulting in anyway shape or form. Insurance laws, policy coverage's and insurance company guidelines can vary greatly from state to state. Be sure to consult with a local agent or broker licensed in your specific state.
