Insurance Copayment Vs Deductible What Is the Difference?
If you don’t know how a health insurance policy works, you can’t make good decisions about your coverage. If the only thing that you are sure about is how much you pay each month, you may be very unpleasantly surprised if you ever have a significant medical expense.
There are three major health insurance cost shares. Not all policies have all three, but many do. The cost shares are:
- Deductibles
- Copayments or Copays
- Coinsurance
It is important to understand all three if you are to make good choices when it is time to purchase your next health insurance plan. You need to know your potential benefits as well as costs.
A health insurance deductible is a specific amount you have to pay before your insurance company pays for certain expenses. On some policies the deductible may apply to hospital stays, but not to doctor visits and not to medications. On other policies your deductible may apply to all medical expenses regardless of the type of provider except certain preventative care costs.
On most policies the deductible is based on health care expenses incurred during a twelve month period. This twelve month period may begin on January first or on the effective date of the coverage and its anniversary.
You can reach your deductible buy paying toward the cost of one major expense or by paying for several smaller ones.
Coinsurance is not based on a specific dollar amount. Coinsurance is stated as a percentage. The typical coinsurance percentage is 20%. However, many policies have 10% coinsurance. Some have 50% coinsurance.
Coinsurance, usually applies to the same types of expenses that your deductible applies to. However, typically you don’t pay coinsurance until you have met your deductible.
If you have a $1,000 deductible, 20% coinsurance and eleven doctor bills of $100 each, you will pay for the first ten visits and pay 20% of the eleventh visit.
Coinsurance is typically limited by your out-of-pocket maximum. Your out-of-pocket maximum may also be known as your stop loss. This can make a big difference in what you need to pay if you have a long-term hospitalization.
The out-of-pocket maximum limits what you have to pay in coinsurance over the course a period of time. That period of time is usually a year.
Copayments are usually smaller dollar amounts that you have to pay whenever you have specific types of medical expenses such as medications. You may have a $20 copayment for each prescription that you fill. You may have a $30 copayment when you have a doctor’s visit.
Copayments are often larger dollar amounts. You may have a $500 copayment for each day in the hospital or a $100 copayment for each visit to the emergency room.
Sometimes the larger copayments are limited, but typically there is nothing in the contract that limits the number of copayments you have to pay. Your out-of-pocket-maximum is not likely to limit your outlays for copayments.
When comparing policies, be sure to learn what expenses the deductible, the coinsurance and copayments apply to. Policies are often very different but often use similar language. Also be aware that not only are companies different, but even health care policies offered by the same company can also be very different. Be sure to ask your agent about anything that you are unsure about.