Understanding Your Plan Costs

Most health insurance plans have three different stages that determine how much you and your health care company pay for health care services:

1Before you meet your deductible
2After you meet your deductible
3When you reach your out-of-pocket maximum

deductible + co-insurance/co-payment = out-of-pocket maximum

Stage 1
Before you meet your deductible

Each plan year begins with a new deductible. You pay out of pocket for your medical services until you’ve paid your deductible in full. Once you’ve paid your deductible, your health plan will begin to pay for its share of covered services. 

Remember that your health plan includes certain services at no cost to you before you meet your deductible. These zero-cost services are defined by the Affordable Care Act’s preventive services provision. We have more information about our zero-cost benefits here.

Before deductible is met

Stage 2
After you meet your deductible

Once you have paid your deductible, you only pay for a portion of your medical services. During this stage, you pay a percentage (co-insurance) of certain medical services and/or a flat fee (co-payment) for others. 

Your health plan pays for the remaining balances after your co-insurance or co-payment. You’ll continue to pay co-insurance and/or co-payments until you reach your out-of-pocket maximum for the year.

After deductible is met

Stage 3
When you reach your out-of-pocket maximum

Your out-of-pocket maximum is the most you will be asked to pay from your own pocket during a plan year for covered services. After that, your health plan pays for all covered services with in-network providers. 

Out-of-pocket limit reached