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How Are the Costs Of Your Health Insurance Plan Made Up?

Thursday, January 17, 2008


If you are not familiar with health insurance then the costs involved in a health insurance plan can seem to be somewhat complex and many people are surprised that, having paid what seems like a small fortune, they find themselves faced with a bill the first time that they submit a claim. Before you are landed with a large medical bill therefore, it is a good idea to take a minute to learn just what sort of costs you can expect to incur on your health insurance policy.

The first and probably most obvious cost is the monthly premium or, if you so choose, the quarterly or annual premium. If you belong to an employer's or union group plan then you will generally be required to pay only a percentage of the premium and this will normally be taken directly from your pay check.
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The majority of health insurance plans will also include an annual deductible which is a sum of money that you will have to pay before your insurer starts to pay out on any claims. So, with a yearly deductible of $1,000 you will have to meet the first $1,000 of any medical bills every year before your insurer will start paying out. You may be familiar with the principle of paying a deductible from your experience with motor insurance policies and, if this is the case, will know that the higher the deductible on your policy the lower your premiums will be. In addition, if you have a family health insurance plan then this will typically include deductibles for each family member covered by the plan.

Some health insurance plans will also include a co-payment which is a fixed amount of money that you will be required to pay towards every medical bill. Exactly how much you will be required to pay in co-payments will depend very much on the type of plan you have. For instance, co-payments on HMO plans are generally lower than those on indemnity plans. In addition, the co-payment will also vary between different forms of medical service and, if you are enrolled in an HMO plan, will generally be higher if you are treated outside of the HMO network.

In cases where a co-payment is not required you will normally find that this is replaced by co-insurance which is similar and is a sum of money, this time expressed as a percentage, that you will again need to pay towards every medical bill. A common co-insurance ratio is 80/20 meaning that your insurer will meet 80% of any medical bill while you pay 20%. As in the case of co-payments, co-insurance will normally rise if, as an HMO plan holder, you are treated outside of the HMO's network. In this case you will also find that, whenever a claim exceeds what the insurance company considers to be 'reasonable and customary', you may be required to pay the additional cost.

By now you will see that comparing different health insurance plans is about a great deal more than just comparing premiums. As a consequence, it is extremely important for you to read the details of any health insurance quote very carefully and avoid the common temptation to simply select the plan with the smallest monthly premium.

If you want to keep costs low and are a member of an HMO plan then you should attempt to stick inside the HMO's network and, if you do feel that it is necessary to go outside the HMO's network, then compare actual treatment costs to what your insurer considers 'reasonable and customary' before you undergo treatment.

You can also keep your costs under control on many plans by adjusting the deductible and by selecting higher or lower co-insurance. Just how this can be done is beyond the scope of this particular article but is a matter of balancing the different costs against the probability of needing to claim against the policy.
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