Print this pageCopay
A set dollar amount you pay when receiving specific services or treatments. In most cases, this will be $15, except for prescription drugs and emergency room visits (see Benefits). Copays do not apply to your deductible, coinsurance, or out-of-pocket maximum.
Deductible
The amount you pay before your health plan starts to pay for covered services. You will be responsible for paying the first $150 of certain covered medical costs before your health plan pays the 80% of the covered services. The $150 annual deductible must be met for each family member enrolled in Basic Health. The deductible does not apply towards the annual out-of-pocket maximum. If you change plans any time during the year, the amount you've paid toward your deductible for covered family members will start over with your new health plan.
Example of How Deductibles Works
Coinsurance
The percentage you pay when your health plan pays less than 100% for covered services. Your health plan will not pay toward services with a coinsurance until you have paid your $150 annual deductible. You will be responsible for paying the 20% of the cost of services that have a coinsurance. Your health plan pays the remaining 80%.
Example of How Coinsurance Works
Out-of-Pocket Maximum
Your coinsurance costs apply toward your out-of-pocket maximum of $1,500 per person, per calendar year. When you or another covered family member reaches the out-of-pocket maximum, you are not responsible for any further coinsurance costs for covered services received by that person during that year. Your health plan will pay 100% of the charges for all coinsurance costs. However, you will still be required to pay applicable copayments.
Example of How Out-of-Pocket Maximums Works
Explanation of Benefits (EOB)
Each time you receive medical services, you will be sent a detailed statement from your health plan that explains which procedures and services were given, how much they cost, how much your plan pays, and how much you pay.
Note: If you change health plans any time during the year, the amount you've paid toward your out-of-pocket maximum for covered family members will start over with the new health plan.
