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Health Insurance: Understanding Your Deductible, Co-pay, & Out-of-Pocket Maximum

Could health insurance be any more confusing? Here’s our quick guide to understanding health plan terminology like premium, deductible, co-pay, co-insurance, and out-of-pocket maximum.

Decoding health insurance terms like deductible, co-pay, and out of pocket maximums.Is anybody else totally confused by health insurance benefits?

Even when insurers break down plan benefits in neat grids, you need to know the difference between deductibles, premiums, out-of-pocket maximums, co-pays, and co-insurance to know what you’re actually paying.

If you already have insurance, it’s important to be prepared for your share of the doctor’s bill, but it’s especially important to understand this stuff if you are shopping for health insurance.

Never has this been more important. With the launch of the Affordable Care Act (Obamacare) on Oct. 1, 2013, nearly everyone in American can now buy health insurance on their own through each state’s healthcare exchange. And in order to compare plans, you must understand how they are priced.

There are several health insurance terms to understand:

  • Premium: The monthly fee for your insurance.
  • Deductible: How much you must kick-in for care first, before your insurer pays.
  • Co-pay: Your cost for routine services to which your deductible does not apply.
  • Co-insurance: The percentage you must pay for care after you’ve met your deductible.
  • Out-of-pocket maximum: The absolute max you’ll pay annually.

Still confused? I’ll explain these terms in more detail below. Need insurance? Armed with this information you can fairly compare plans through your state healthcare marketplace or online with a service eHealthInsurance, an easy way to compare and buy health insurance plans in most states.

PREMIUM

Your premium is the amount you pay into the insurance plan on a regular basis.

If you belong to an employer-sponsored plan, the premium is likely deducted from each paycheck as pre-tax dollars. If you purchase your own health insurance plan, you may have the option to pay your premium annually, quarterly, or monthly. Health insurance premiums vary greatly depending on what medical expenses the plan covers, which doctors you can see, and how much you will have to pay in other ways when you use services.

DEDUCTIBLE

Your health insurance deductible is the amount that you will have to pay annually for your healthcare (such as surgical procedures, blood tests, or hospitalizations, but not routine office visits) before the health insurance pays anything.

For example, if you have a $2,500 deductable and undergo three $1,000 procedures in a year, you will have to pay the full bill for the first two procedures and $500 of the third…your insurance will cover half of the third procedure.

Increasing your deductible is the easiest way to lower your premiums and, if you’re mostly healthy, might be a good idea. Just understand, however, that if you have a $10,000 deductible and get sick, you could end up with $10,000 of medical bills in a year. Typically, your deductible does not apply for preventative health checkups and many routine health services…you’ll just pay a co-pay instead.

CO-PAY

Your co-pay is the fixed amount you pay for using routine services like visiting your primary care physician or an emergency room or purchasing a prescription drug.

In most cases, the payment is the same regardless of the extent of the visit or the cost of the drug. For example, a plan may require co-pays of $20 for office visits, $100 for emergency room visits, and $15 for generic prescriptions or $30 for name-brand drugs.

CO-INSURANCE

Co-insurance is similar to a co-pay, although co-insurance generally applies to less routine expenses, and is expressed as a percentage rather than a fixed dollar amount.

Co-insurance is in addition to your deductible. So if your plan has a $100 deductible and 30% co-insurance and you use $1,000 in services, you’ll pay the $100 plus 30% of the remaining $900, up to your out-of-pocket maximum. You may find plans with no co-insurance requirements, some with 20/80 or 50/50 coinsurance, or other combinations.

OUT-OF-POCKET MAXIMUM

Your out-of-pocket maximum is an important feature of your health plan because it limits the total amount you pay each calendar year for healthcare including co-pays, deductibles, and co-insurance.

If your policy carries a $2,500 out-of-pocket maximum and you get sick and require a lot of healthcare services, the most you will pay in a year is $2,500. After that, insurance picks up the rest of the tab.

Deductible vs. out-of-pocket maximum

The difference between your deductible and an out-of-pocket maximum is subtle but important. Out-of-pocket maximum is typically higher than your deductible to account for things like co-pays and co-insurance. For example, if you hit your deductible of $2,500 but continue to go for office visits with a $25 co-pay, you’ll still have to pay that co-pay until you’ve spent your out-of-pocket maximum, at which time your insurance would take over and cover everything.

A note about lifetime maximums

Insurance plans used to frequently have lifetime maximums, often of $1,000,000 or more. The recent healthcare reform has made this illegal, however. These lifetime maximums could be devastating if you ever required intensive surgery or cancer treatments, which often can cost up to $500,000 a piece. If you needed more than one, you could basically run out of health insurance when you need it most.

Need to compare plans? You can compare and in some cases even buy your own health insurance online. Start comparing plans with eHealthInsurance, our recommended partner.

About David Weliver

David Weliver is the founding editor of Money Under 30. He's a cited authority on personal finance and the unique money issues we face during our first two decades as adults. He lives in Maine with his wife and two children.

Comments

  1. Thank you. This was very direct and very helpful.

    • My question is can a primary physician that accepts your insurance bill you for what the insurance doesn’t pay minus the co-pay?

  2. Sofia Lueck says:

    This still is not really clear about out-of-pocket. In my case, the insurer says I have to spend $3,000 before they pay anything. Aren’t they supposed to pay their share after the deductible is met? How do they figure their share to be paid?

  3. Sofia, this is how the co-pay, deductible and co-insurance are being stacked:
    – you pay co-pay for any doctor visit; of no other procedures were involved that will be it; the insurance and their arrangement with the doctors/hospital network will take care of the rest;
    – some plans will include zero co-pay and 100% co-insurance (the insurance co pays all) for selected services like mammograms and pap smear tests etc. so these do not cost the insured co-pay or else;
    – you pay up to the deductible amount for any procedures like special tests, treatments, surgeries etc.; That is why a higher deductible may not be that bad since you only pay in to it’s amount in case of more serous needs, not going to the doctor etc.
    – after the deductible is paid any further costs are split between the insurance co and the insured; if the co-insurance arrangement is 80/20 for example, the ins. co pays 80% and the insured 20% of any claims.
    – where the out of pocket limit kicks in is when the insured while paying these 20% (and in some cases all co-pays, and deductibles) reaches the out of pocket amount (also referred to as stop-loss for the insured), after that the insurance company pays all.
    It ls very complicated but the structure gives the ins company the ability to offer flexible plans for different needs.
    Insured individuals can pick deductible, out-of-pocket amounts, annual and life time limits etc.

  4. Hi,

    Is it possible to request the cancelation of my individual plan deductible that my employer offered me ? I know the answer might be obvious but I am confused because I was not expecting such a high deductible.

    I am very disappointed…

    thank you,

    Ray

    • Danielle Dunn says:

      You should be. You’d would have to speak to HR or whoever handles your benefits about it, though.

  5. Willie H. Smith says:

    I thought the deductible was $155.00, but I have already paid $186.46, and I received another bill for $78.83. When does it end?

  6. I don’t think it ever does!! I have the same problem. Now I’m thinking that I didn’t know to consider co-insurance which apparently takes an additional percentage above the deductible….I would love to know if I am correct….

  7. Your deductible is your deductible, it doesn’t change; however, you need to know how it is applied. An office visit can have a copay and xrays can have a deductible even though it is the same office visit. It could be that there is a separate deductible for in and out of network providers. Ask specific questions from your insurance agent time and again if necessary. It is your right to understand how and when they use your deductible and for what service.

  8. It is too bad so many patient seem to think of themselve as a victim. What all patients need to do is take the responsibility of knowing what their plan does and does not pay. There are customer service agents that will spend hours with you explaining everything about your plan if you ask. What other product do you buy where you expect someone else to take responsibility for your lack of research?
    What happens every day in every medical office is that we absorbe thousands and thousands of dollars in co-pays, co-insurance, and deductibles because someone wants to purchase the least expensive plan, then winds up having to use the insurance for an emergency. So now they can’t pay their $6000 deductible, so they just go file banckruptcy and viola; to the insurance company the deductible looks paid but the doctors office has to write it off.
    Now times this situation mulitple times every month and you tell me why you think a physician has to charge so much, not to mention the trailer park mama that wants to get rich off a malpractice suite.

    • K, I agree with you, know what you are getting. I’ve been burned too many times. However, I’ve requested a copy of the policy so that I can see what is covered and what is not b/4 I need it. You can’t get one unless you apply/buy. (kinda of like you need to pass the bill to see what is in it) I don’t want a glossy brochure or summery of benefits or an hour with someone who only want to sell me something. I want to read for myself.

    • Yes, you’re right. Forget all these ignoramuses that don’t understand the complete ins and outs of medical/legal terminology! And trailer trash, well they don’t count as humans do they? Even if tough luck got them their discriminatory status you label them with. Heck, it should just be all good people like you in this world and everything would be OK. The sad thing is that profit is placed as a motive to maintain basic health care, which if healthcare was just an option for decent health, kind of like an option for leather seats, that would be reasonable.
      In a society that is no longer agrarian with a widely dispersed population, but one that is now being weaned on petroleum byproducts and empty calories we have forced a health dilemma upon society that necessitates a basic level of vaccinations and healthcare; to deny people that in the name of profits is unjust.
      I do wish you all good health, good healthcare and fair and reasonable healthcare coverage.

    • insurance consumer says:

      This stuff is not clear cut. Calling to talk to agents and customer service to ask questions is hardly the experience you describe. Why the heck do you think there are websites like this attempting to explain these terms in plain English? And even now, they’re leaving important stuff out, and they can’t explain fully because each provider had different definitions of terms.

      No one is going to spend hours counseling you on what plans do and don’t do. That’s a fantasy. I can’t even call my customer service to find out if a procedure is covered without a procedure code, and even then it’s a best guess.

      Of course people want to buy the cheapest plan they can, insurance is expensive! It’s hard to find real information about specific policies before you buy them, and insurance agents often can’t tell you what is and isn’t covered before you buy the policy and send in a pre approval request. Someone who works double shifts in a kitchen six days a week will hardly have the energy or time to learn legalese and medical speak, then sift through all of the plans that are in his or her price range.

      So, you buy the wrong insurance because it’s all you can afford, or because it seemed like it would cover your issues. Then your approval is denied, you’re stuck paying for insurance that doesn’t cover you, and if you need a procedure, you pay for that out of pocket too. Yeah, it’s these trailer mamas that are scamming the system all right.

      You talk about trailer park mama who wants to get rich off of a malpractice suite? What about the doctors that want to get rich off of sloppy work and unnecessary procedures? But, you’re right, I’m sure there are lots of people who had bad work done who are jumping for joy because they’re the Beverly Hill-billies now.

  9. We’ve met our $1500 out of pocket last year – and are now being billed by an “out of network” provider for $4,600. And of course, our insurance paid based on their Usual and Customary Reasonable Price schedule. They paid $6,500 to this provider. What in the world? We pay a lot per month to have insurance — and still pay for services on as needed basis. We also are being billed from a medical laboratory $500 for bloodwork b/c they state “the claim we received does not indicate this service was provided for treatment of an illness or injury and therefore, would not be covered by BCBS. If this service was related to an illness or injury, please return this claim report with a letter from your Doctor which indicates the patient’s illness.” What in the world?

  10. Roger Dane says:

    Insurance? Wow… try HIPAA which is what I ‘had’ to take after being caught in a job change (I have cancer, my job was outsourced and I was on COBRA) so when COBRA ended and with the ‘existing’ cancer condition NO ONE except HIPAA would insure me… of course 50 years ago I’d be dead, so there is some balance here.
    But I have a $5000 deductible (and still pay $800 monthly for the policy) and my meds cost $11800.00 month (I have to pay $1000 for pharm deductible then just $50 per refill so it is almost doable while on unemployment!). I still don’t want the government running Health care but the doctors and hospitals all are scared of lawsuits to I’d like to see lawyers out of the insurance/health business. But that will happen if hades freezes over!
    All stay healthy!

  11. Roger…apparantly you have the money to pay a 5000.00 deductible, a 800.00 month for the premium and 1000.00 for meds deductible..Are you kidding me??/ What MiddleClass American has that kind of money to pay insurance, let alone when you have cancer you have to eat properly, supplements…etc that is not covered under insurance to stay alive!!! You still don’t want the goverment involved in your healthcare?? You don’t have heathcare you are paying everything!! Why do we live in a country that as long as you have health insurance its ok..What about the millions and millions who can not afford this. This is unreal..Wake up people this is cruel and greed beyond belief!!! HealthCare is not a luxery it is a human right!!!!

    • OK, in exchange for paying about $27,000 per year out-of-pocket, Roger gets about $135,000 in pharmacy benefits, plus other benefits. THAT does not sound like “greed” on behalf of the insurance company. It is a very tough situation indeed, but at least he’s not trying to pay forr it ALL himself. Oh, and Kelly- instead of spending your tax return on something frivolous, and insisting it’s your right to have cable tv, private Internet access, smartphones, vacations, and $5 coffees, you should have 6-8 months’ pay saved up to help pay for emergencies, like unemployment or a health condition. That’s where middle-class Americans get that kind of money.

  12. What if a plan says that it has $0 individual/$0 family co-insurance… is that good or bad?

    • Danielle Dunn says:

      That’s a good thing because that means you don’t have to pay anything. But you may want to check to see if you are responsible for any copays or if you have any out of pocket limits to meet though.

  13. Hi all, I’m going for vascular surgery and have been informed that it will cost over $3,000 dollars (due to out-of-pocket) before the insurance covers 100% I work at a cafe and can’t afford the expense and rent. The surgery is medically necessary, is there anything I can do??

    • Hire a medical billing advocate. Most do not charge unless they save you money. Check out Medical Billing Advocates of America.

  14. Once the OOPM is met, does insurance cover all expenses, including prescriptions? That is the only part I am unclear about.

  15. I am an International Student with a Pre existing condition called THALASSEMIA. I need Blood Transfusions every 21 days no matter what. I am on a Aetna Students plan which pays 80% of my bills & t20% i am expected to pay. The 20% amounts to USD 1200 every month approximately!!
    My Max out of pocket is USD 5000 and the Maximum is USD 100,000!
    I Would reach my Max out of pocket VERY quickly. What will happen after that??
    Will the insurance company pay 100% of my medical bills then? Is the Maximum limit of 100,000 USD calculated at actuals after each bill (eg if my medical bill after i have exhausted my out of pocket maximum comes to 10,000 USD. Then the Insurance company will pay for 10 more medical bills OR will they consider 20% amount ie. USD 1200 which I was paying & keep paying till they reach USD 100,000???)
    PLEASEE clarify this as I am tired of asking my insurance company over teh phoen & they fail to understand.

    • Your out of pocket max is the max amount you are required to pay per year. That includes deductibles, copays, and any co-insurance. Once you reach your out of pocket max your insurance pays 100% up to their maximum yearly payable amount of $100,000. If your insurance reaches that $100,000 max, anything over that is your responsibility, meaning you have exhausted your insurance benefits for the year. This is the case each year. Just make sure to verify that the $100,000 is a yearly maximum benefit payable and not a lifetime maximum.

  16. I am double insured my employer which has a 20.00 co-pay for office visits and my husbands insurance which has a 30.00 co-pay I am not sure why I would have to pay a co payment at all if my insurance pays all but the 20.00 why would the secondary not pay the difference?

  17. Our new insurance has no annual deductible. We have a $5000 yearly out of pocket maximum. How does this work?

    • Danielle Dunn says:

      You may just be responsible for co-insurance, which is a percentage of the charges you would have to pay and the insurance would pay the rest. For example, if insurance pays 80%, you would have 20% coinsurance. You may want to double check with your insurance company just to be sure though.

  18. Roy Thurman says:

    I draw 596.00 a mo. on disability . My wife works at a plant and makes bout 26,000 a yr. My question is why do they take out almost 100.00 per mo. from my check when my wifes insurance takes care of 80% of it . seems like double dipping

  19. This helped a bunch after a recent couple big medical visits. Thanks!

  20. I just want to know how premium works and how out of pocket works. and here finally i just want to know that what is the difference between out of pocket and premium if somebody explains me i will be really clear on it………… Please some body experts can help me………….Thank you

    • Danielle Dunn says:

      Hey Rajesh ( Warning: I’m going to be a little long winded here so hang on :-) )

      Your premium is what you pay to the insurance company every month for them to “cover” you. Out of pocket is the money you pay to the provider or whoever provides you medical services (hospital, ambulance, ect.) .Usually, the term “out of pocket” applies when you have a deductible to meet or co-insurance to pay ( or both) , in which you have an “out of pocket max”, or OOP Max This is the maximum amount of money that you pay and then insurance takes care of any (covered) services 100% and you pay nothing to the provider, but you will still need to pay your premium. Co-pays generally aren’t included in OOP (although I have come across a rare few where they are). Just to show how it all works, the following is what my medical coverage is:

      -Deductible:$2500 ( If I end up in the hospital or if I’m having a major surgery or an MRI/ CT/ PET scan, this would apply. I’d have to pay this amount before my insurance will pay anything)
      -Co-insurance: 80/20 ( After meeting my deductible, my insurance will pay 80% of the charges and I pay 20%)
      OOP Max: $5000 ( This is the maximum amount of money I pay period. I’d be covered 100% after. For me, it happens to include my deductible and co-insurance together. Some plans OOP max applies just to co-insurance, so you may want to double check what your plan says).

  21. I have had the same health insurance benefits for 10 years with BCBS. I have a low deductible and met it by February 2012. I see many out of network doctors which I pay upfront and then I am reimbursed. As of August I met my out of pocket maximum and was being re-imbursed 100%. So all was well until now. As of Sept 1 my health insurance went up, higher everything, but I have a very good plan and with the state of the economy and everything I understood why it was going up. I called my HR department with 1 question, will I have to meet the new deductible and out of pocket max since it will change Sept 1. Answer, NO it will go into effect January 1. The only things that are changing are RX and co-pays. Well my EOB yesterday stated differently. I called BCBS and they said I have to meet the new deductible, difference of at least as well as the new out of pocket max. Can they do that? 2 deductibles in 1 year?

  22. There is one other big cost not on the list – amounts above usual customary and reasonable. When you use in network providers your list is complete.

    When people go out of network all bets are off. Providers charge what they want, and your insurance company does not apply these amounts to your maximum out of pocket amount.

  23. britainguy says:

    thanks for this, its very clear but i still have one question.
    me and my husband are in the same insurance, our out of pocket max is 3000 individual and 7500 family, right now im the one using the services, and im reaching my OOPM soon, but im still confused that will it go by individual or family when we are together in the same insurance but the im the only one using it.
    hope anyone can help me
    thanks

  24. David,

    Finally someone explains these terms in a clear way! I was very confused about deductibles until now. I was under the assumption that deductibles also applied to routine doctor visits and other non surgical procedures.

    Thanks. for the clarification!

    Bitter Sweet Fitness

  25. David,

    I’m in Illinois and just got off the phone with BCBS IL customer service. They contradicted something from your article. Beginning in 2014, they have co-pays related to outpatient surgery, inpatient hospital stays, emergency room vists, etc. and these co-pays along with office visit and prescription co-pays will NOT count toward your maxiumum-out-of-pocket costs.

    That being said, I’m still not convinced you are wrong, because I had a BCBS IL broker confirm what you have stated in the article, that co-pays, etc are all counted toward your maximum-out-of-pocket costs.

    I hope we will be able to get real clarity on this before the middle of December when we must sign up for the UNaffordable insurance requirement.

    Frustrated beyond belief !

  26. This was a great article! Answered all my questions and clarified things I wasn’t 100% positive on. It was simply put and direct, thank you so much for posting this. Like many others I was mostly confused on a deductible vs OOP (out of pocket) I have a clear understanding now. Thank You!

  27. This is the best explanation I have read. Thank you so very much for it, I can finally make sense of the choices I have.

  28. Please help! I feel I’ve educated myself the best I know how but still have questions. I have spent hours on the phone with customer service reps that are not able to give me a solid answer. I am looking to purchase private individual coverage including maternity. I found a plan that has a rather high monthly premium, and a $750 individual deductible and $1500 family deductible. Once the deductible is met, there is 0% co-insurance. There is however a max out of pocket of $12,000. I understand copays, deductibles, etc go toward the max out of pocket but what else would? They way I understand the plan myself and my dependent would be covered 100% after the family deductible is met (minus copays, prescriptions) but what else could cause me to have to pay the $12000.
    Thanks for you help. As insurance really can be that confusing!

    • David Weliver says:

      I could be missing something, but I believe that with 0% coinsurance, the only expenses you’d be responsible for after meeting your deductible are co-pays.

  29. David,

    I am searching for a new healcare plan and have a question for you. When it comes to OOP limits all of the BCBS plans that I found indicate that premium, balance-billed charges, health care this plan doesn’t cover, out-of-network deductible, copays, coinsurance and precertification penalties will not be included in the OOP limit. I understand why most of these expense will not be included in the OOP limits, except copays & coinsurance. While copay amounts are relatively insignificant, coinsurance amounts can make a huge difference. I am not seek and hope that nobody in my famile will be seek, but how can we ever reach OOP limit if coinsurance will not be included? Plans that i am looking at have OOP limits (6,350/12,700) almost 3-times higher than deductible (2,400/4,800)
    D.

    • David Weliver says:

      I don’t know the intricacies of every plan, but I would be surprised if a plan is legally able to EXCLUDE coinsurance from the out-of-pocket max. I would double check that and if it’s the case find another plan. This is an explanation taken directly from a Blue Cross/Blue Sheild web site (granted plans differ by state):

      Your premium + your deductible + any coinsurance you must pay (up to your out-of-pocket maximum) + any copayments = the most you will pay for healthcare each year (for covered services).

  30. I called united healthcare because I was charged copays after being at my max out of pocket. I was told that max out of pocket does not include co pays. Is this possible?

    • Brittney

      It is possible. Its not a requirement that co-pays HAVE to go toward out of pocket. It really depends in the plan. I have UHC too and my co-pays don’t go toward my OOP max.Just deductible and co-insurance.

    • Tim (via email) says:

      Current plans yes, copays and deductibles are generally not included in max oop calculations. New ACA compliant plans I’ve been told by numerous representatives will include copays and deductibles in maximum out of pocket calculations.

  31. Can anyone explain this to me in a way that even a child can understand? I truly understand NOTHING about health insurance. I’m 24 and it’s embarrassing but I really just do not get anything dealing with numbers either. Please and Thank you!

    Individual Deductible $6000.00
    Family Deductible $12700.00
    Coinsurance 100%
    Individual Out-of-Pocket Maximum $6000.00
    Lifetime Benefit No Limit