Frequently asked questions
How are my premiums calculated each year?
Your Health Plan Premiums are based upon utilization. How often and for what services are used plays a part on how your premiums are determined. The more you use, the more you pay.
Does my health plan have a deductible?
Maybe. If your employer chose a 7b plan, chances are you have a deductible on your plan. If you are not sure what plan you have, check with your employer.
What is a deductible?
A deductible is a fixed amount of money you (the insured individual) must pay before the health insurer pays its share. For example, if you have $500 deductible, you will have to pay for services (doctor's visits, prescriptions, etc) up to the deductible amount before the insurance company starts to pay for care. Deductibles are usually calculated annually, so you have to meet this amount each year. Generally, health plans with high deductibles have lower premiums.
What are co-payments?
Co-payments are the amount you must pay out-of-pocket before the health insurer pays for a particular visit or service. For instance, you will pay a $15 co-pay for a doctor's visit or to obtain a prescription. Note that your co-payment does not include taxes, which your Provider may pass down to you. Taxes are not assessed on the amount of the co-payment, rather it is assessed on the eligible charge of the service your receive. For instance, if the eligible charge for a regular office visit is $100, you are responsible to pay the tax assessed on $100. Add that to your co-payment and this is what you will be responsible to pay.
What is Co-Insurance?
Instead of, or in addition to paying a fixed amount (co-payment), the co-insurance is a percentage of the total cost that you may also have to pay. For example, you may have to pay 20% of the cost of a surgery over and above a co-payment (if any), while the insurance carrier pays the remaining 80%.
how much co-payments and co-insurance do i have to pay?
Depending on the services you need, you may end up paying more in co-payments and co-insurance. To protect your wallet, your health plan has an Out-Of-Pocket Maximum. This is your total payment obligation. Your obligation ends when you reach this amount. This means, you will not longer have to pay for any co-payments or co-insurance for any covered service. Your insurance carrier will be responsible to pay for covered services thereafter. Out-of-Pocket maximums reset each plan year. Note that Out-of-Pocket maximums are generally high (refer to your health plan's SBC for amount). If you're relatively health and may never reach the maximum.