Medical Plan Basics

Use the definitions and examples below to better understand how how health plans work and what your costs may be.


What is a Premium?

The premium is the ongoing amount you or your employer pay for your health insurance plan in order to maintain your health coverage. You are responsible for your premium whether you use medical services or not. In most cases, it's paid monthly, but can be paid quarterly or yearly.

 

What is a Deductible?

A deductible is the amount you must pay toward your health insurance costs before your health plan begins to pay for your covered services. For example, if you have a $1,500 deductible, your plan won't pay for some services until you've paid $1,500.

 

What Is Coinsurance?

Coinsurance is the percentage of eligible expenses you must pay for covered health services after you meet the annual deductible.

For example, let's say it costs $100 to see your doctor. If your coinsurance is 20%, you must pay $20 and your health insurance plan pays $80. You must pay the entire amount if you haven't met your deductible.

 

What Is an Out-of-pocket Maximum?

The out-of-pocket maximum, or OOPM, is the most you have to pay out of your own pocket for medical services under your insurance plan during the year. Your deductible, coinsurance, copays and any other expenses for in-network essential health benefits (EHBs) apply to the OOPM.

 

Examples

Review three hypothetical examples to see how the 2018 plans work based on health care needs:

 

Use the ​Plan Comparison Tool to find out what plan is right for you


​​Watch a video to learn 7 Ways to Save on Prescription Drugs

Estimate your drug costs for 2018 using the Prescription Cost Estimator Tool


Find more helpful tools in the Resource Library