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About your coverage: Health insurance 101
Our goal is to help you understand your health insurance, coverage, and financial responsibilities.
Sharing the cost of care Your policy may use a system of cost sharing that can include a copay, coinsurance, deductible or any combination of the three.*
1 Deductible
Each time you receive medical services, you’ll pay the bill toward these services up to a certain amount. This amount is your deductible, which is what you must pay for covered health care services each year before we begin to pay. Coinsurance † Once you’ve paid the deductible amount, your insurance will then start splitting the cost of additional medical services with you. This is known as coinsurance, where you only pay a percentage or part of the total cost of services and we’ll pay the rest. Deductible and coinsurance limit There is a dollar limit to the amount you’ll pay toward your deductible and coinsurance. Copays A copay is a fixed dollar amount, which you pay at the time you receive medical services (for things like an office visit) and prescriptions. All your copays add up toward your Maximum Out-of-Pocket total. Maximum out-of-pocket There’s a dollar limit to all your cost sharing. You reach this amount by means of your deductible, plus your coinsurance, plus your copays. Once this limit is reached, you’ll pay nothing on subsequent covered medical charges for the remainder of your policy year.
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* Not all of the cost-sharing terms listed here apply to all members. Refer to your Member Certificate to understand which apply to you. Smart Plan medical copayment applies towards the maximum out-of-pocket, which is the amount you are required to pay toward the covered cost of your healthcare. The out-of-pocket maximum amount is calculated on a contract year or calendar year basis. For members with PPO and POS Smart Plans, coinsurance and copays apply. † Coinsurance is your share of the costs of a covered health care service. It’s calculated as a percent of the allowed amount for the service.
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