Whether you’ve recently changed health insurance plans, purchased health insurance for the first time, or aren’t sure if the health insurance you already have has changed from last year, there are a few crucial numbers you need to know so you can understand and budget for your health care costs this year.

Premiums and Deductibles

Your premium is the amount you pay, typically each month, for health insurance. This is a fixed price that won’t change throughout the year; however it can change from year to year. The premium is often one of the biggest factors people use to determine the right health insurance for them. Make sure to review your renewal premium notice each year to see if your premium changes for the next year. The amount you owe for premiums may also change if the subsidy you receive changes due to a change in income, change in family size, or other factors.

The deductible is the amount of money you will be responsible for paying out-of-pocket for covered medical expenses if you need medical care before your insurance company will begin to pay. After the deductible is met for the year, your insurance will begin to make payments for claims on covered medical expenses.

Many plans cover routine and preventive care, like vaccinations, annual physicals, or lab work. For these services, you may only have to pay the copay. You can contact your insurance company so you know which services will go towards your deductible and which will not.

Premiums and deductibles are directly related; plans with higher premiums generally have lower deductibles, and plans with lower premiums have higher deductibles. High deductible health plans (HDHPs) often offer a health savings account (HSA) that allows you to deposit pre-tax dollars to pay for qualified medical expenses.

 

Co-Payments and Co-Insurance

These are two ways in which you and your health insurance provider may split the cost of your care. The primary difference between a copayment and coinsurance is that a copayment is a fixed fee, while coinsurance is a percentage split. For more information, see our article on the differences between a copayment and coinsurance.

A coinsurance payment is difficult to predict because you may not know in advance how much a service is going to cost. However, if your plan has copayments, you should know what these numbers are. You may have different copayments for different services, including:

• Brand name prescriptions
• Generic prescriptions
• Sick visits
• Visits to the emergency room
• Inpatient hospital care
• X-ray, lab, or diagnostic services
• Specialist visits

You can find your plan’s copayments in your summary of benefits. If you’re thinking about switching to a new health insurance company, HealthMarkets will do the legwork for you at no cost, so you don’t have to call up each individual company to find the lowest copayments.

 

Out-of-Pocket Maximum

An out-of-pocket maximum is the most you’ll have to pay during a policy period (usually a year) before your health insurance plan will pay for all covered benefits. Premiums generally do not count towards your out-of-pocket maximum, but deductibles, coinsurance, are included. For 2017, the out-of-pocket maximum for a Marketplace plan can be no more than $7,150 for an individual plan, or $14,300 for a family plan.

A recent survey revealed that 20% of respondents avoided visiting a doctor for a general health issue within the past 12 months because of cost concerns. 44% of respondents didn’t know how much they would have to pay out of pocket for prescription drugs, and more than 61% did not know how much it would cost to get treatment at an urgent care or walk-in clinic.

Health care is essential to your quality of life, and you should never skip a doctor visit because you’re confused or concerned about the numbers.

Don’t let confusion or lack of information stand in the way of making wise health care choices. Consumers should take the time to review their current plan to ensure it is still the best option for them. In addition to that, each year there may be new insurance companies and plans to choose from.