Knowing your deductible matters
Understanding your insurance is very important to avoid being caught off-guard. Before you reach your annual deductible, healthcare costs, including appointments, can be higher. After your out-of-pocket spend meets or exceeds the amount of your deductible, your insurance will generally cover more, reducing your out-of-pocket costs.
What is a deductible?
A deductible is the amount you have to pay out of pocket each year before your insurance starts helping more with your medical costs.
How it works
You pay for medical services yourself until you hit your deductible.
After that, your insurance starts covering a bigger portion of your care.
Example: If your deductible is $2,000, you pay the first $2,000 of covered medical costs. After you meet your deductible, your insurance begins covering a larger share of your costs. You may still have copays or coinsurance until you reach your out-of-pocket maximum.
Helpful tips:
Your insurance sets your deductible amount.
Not all services count towards your deductible.
Circle Medical doesn’t determine coverage; your insurance does.
What is a copay?
A copay (or copayment) is a fixed amount you pay for certain healthcare services, like a doctor's visit or a prescription. You typically pay this amount at the time of service, regardless of whether you've met your deductible. For example, your copay might be $20 per office visit or $10 per prescription refill.
Helpful tips:
Copays usually don't count towards your deductible, but they do count toward your overall out-of-pocket maximum
Copay amounts can vary based on the type of service and your insurance.
What is coinsurance?
Coinsurance is the percentage of the cost you pay for covered healthcare services after you've met your deductible. Your insurance pays the remaining percentage.
How it works
If your insurance has an 80/20 coinsurance, after you meet your deductible, your insurance pays 80% of the covered costs, and you pay the remaining 20%.
Helpful tips:
Coinsurance is usually expressed as a ratio (e.g., 90/10, 70/30).
Your coinsurance obligation continues until you reach your plan's out-of-pocket maximum.
What is an out-of-pocket maximum?
This is the most you pay for covered services in a plan year. Once you spend this amount (through deductibles, copays, and coinsurance), your insurance pays 100% of the costs for covered benefits.
Learning more about your costs
To get a clear picture of your potential out-of-pocket expenses:
Review your summary of benefits: This document from your insurance outlines your deductible, copays, coinsurance, and out-of-pocket maximums.
Check your explanation of benefits (EOBs): After receiving care, your EOB details the costs, what your insurance covered, and what you owe. It also shows how much you've contributed to your deductible. Read our guide to learn more about Understanding Your Explanation of Benefits.
Contact your insurance: Call the member services number on your insurance card to ask specific questions about your plan's costs for different services.
Use your insurance’s mobile app or web portal: Many insurances provide online tools to track your deductible progress and view claims information.
Understanding these key insurance terms will empower you to better anticipate and manage your healthcare costs.