All health insurance requires consumers to pay some of the cost of covered health care services. This is called “cost sharing” or “out-of-pocket” costs. Cost sharing varies with different types of health plans, but most will have a copayment, coinsurance or deductible amount.
Cost Sharing Requirements
- Your plan may require you to pay before the plan begins to pay. This is called a deductible (e.g. if your deductible is $500 per year you would pay the first $500 of incurred medical expenses). Plans also may charge a deductible for certain services (e.g., you pay $100 for a hospital stay).
- You also may need to pay a portion of each visit called a copayment (e.g., you pay $10 for each prescription medication). You may have a copayment for emergency room services. Also check your plan for details emergency services for non-emergency problems.
- Some plans require you to pay part of each service as a coinsurance (e.g., 20% of the cost of a service).
Children’s Preventive Services
Children’s preventive services, such as well-child checkups and immunizations, may or may not be covered without cost sharing. If your child has a new health problem or established medical problem that requires discussion or management (in addition to your scheduled well-child exam) your insurance company may require a copayment or deductible. Also, some health plans may not cover behavioral/mental health screenings that are typically done during a well-child exam. You should carefully review your plan’s benefit description for details. The best time to review a plan is before you sign up with it.
