Health Insurance FAQs | PBC

Copay:

Co-pays are your fixed fee for certain covered medical services. The Copay is a set amount you pay each

and every time you use a particular service like visit the doctor, an X-ray, or a medication.

The amount of the copay is preset by your insurance provider and will be the same fixed amount no

matter how often you use the plan.

The most common copays apply to primary care, specialist, and urgent care visits as well as prescriptions

but not every plan has copays.

Deductible:

The deductible is the amount you pay for covered health care services before your insurance plan starts

to pay. Typically, if a service doesn’t fall under a copay, it falls under your deductible instead.

It’s important to note that your premium (that monthly membership fee) and your copays do not count

toward your deductible. Also, the deductible renews each year (usually calendar year) and you have to

start over towards meeting your deductible.

Coinsurance:

Co-Insurance is a cost the insurance carrier shares with you for covered medical services. Coinsurance is

usually described as a percentage of the expenses shared between you and the insurance company. It

applies after you have met your deductible and before your out-of-pocket maximum has been met.

Once you reach your deductible, coinsurance applies, and you and your Health Insurance plan share

your medical costs. For example, coinsurance of 80/20 means that your insurance will pay 80% of the

cost and you will pay 20%.

Out of Pocket Maximum:

As the name implies, the out of pocket maximum is the most you have to pay for covered services in a

year (usually calendar year). After you spend this amount on deductibles, copayments and coinsurance,

your health plan pays 100% of the costs of covered benefits.

Frequently asked questions