Premium
The premium is the amount you pay to keep the coverage in force. It is generally due whether or not you use medical care.
Deductible
The deductible is the amount you may need to pay for certain covered services before the plan begins sharing more of the cost. Some services may be covered before the deductible, depending on the plan.
Copays and Coinsurance
A copay is usually a fixed amount for a covered service. Coinsurance is usually a percentage of the allowed cost. Plans can apply these differently before or after a deductible, so review the actual plan documents.
Out-of-Pocket Maximum
The out-of-pocket maximum is an important protection for covered in-network care, but not every expense necessarily counts toward it. Premiums generally do not count, and out-of-network rules can differ.
Compare a Normal Year and a High-Use Year
A lower-premium plan may be attractive if you expect little care, while a higher-premium plan may feel more predictable if you expect frequent visits, procedures, or prescriptions. The better comparison is the total cost under realistic scenarios.
Questions to Ask
- Which services apply to the deductible?
- What copays or coinsurance apply after the deductible?
- What counts toward the out-of-pocket maximum?
- How does the plan treat out-of-network care?
- Are prescriptions subject to a separate deductible or tier structure?