A Working Checklist for Premiums, Deductibles and Copays
Premiums, Deductibles and Copays: what is worth doing, what is worth avoiding, and when to stop and see a doctor.
The main ways a health plan splits the cost of care with you: a monthly premium, a yearly deductible, and copays or coinsurance after that. Comparing plans on the premium alone is a common mistake, because a low premium often comes with a high deductible that you pay before the plan shares most costs.
Key takeaways
- Premium: the amount you pay for coverage each month, whether or not you use care
- Deductible: what you pay for covered services each year before the plan starts to pay its share
- Most useful single change: Estimate a full year of costs: twelve months of premiums plus the care you expect to use.
- Commonest mistake: Choosing the cheapest premium without checking what you would pay if you got sick.
- See a doctor if any of the signs under "When to speak to a doctor" below apply to you.
Do
- Estimate a full year of costs: twelve months of premiums plus the care you expect to use
- Check whether your regular prescriptions and doctors are covered before choosing a plan
- Look at the deductible and out-of-pocket maximum together, not just the premium
- Read the plan's Summary of Benefits and Coverage, which uses a standard format for easy comparison
- Ask your plan or employer benefits office if any term on your card or bill is unclear
Do not
- Choosing the cheapest premium without checking what you would pay if you got sick
- Assuming a copay means the service is fully covered after you pay it
- Skipping needed care because of cost without first asking about cheaper options
The numbers behind the list
Where the items above come from.
| Measure | Figure |
|---|---|
| Premium | the amount you pay for coverage each month, whether or not you use care |
| Deductible | what you pay for covered services each year before the plan starts to pay its share |
| Copayment | a fixed dollar amount for a covered service, such as a doctor visit or prescription |
| Coinsurance | your percentage share of a covered service, usually after the deductible |
| Preventive care | many plans cover listed preventive services before you meet the deductible |
If you change one thing
Estimate a full year of costs: twelve months of premiums plus the care you expect to use. It is first on the list above. If the rest feels like too much at once, start there and leave the others.
Related topics
- Original Medicare (Parts A and B): What Published Guidance Supports (Medicare and Medicaid)
- What the Guidance Really Says About Benefits and Financial Support (Long-Term Conditions)
- Annual Wellness Visit: What the Evidence Actually Says (Preventive Care)
- The Evidence on Travel Insurance and Healthcare Abroad, Without the Hype (Travel Health)
Where to go next
- The First Steps With Premiums, Deductibles and Copays
- Premiums, Deductibles and Copays: Common Questions Answered
- Premiums, Deductibles and Copays — the reference entry
- Health Insurance: The Complete Guide
- Out-of-Pocket Maximum: Sorting the Evidence From the Noise
- What the Guidance Really Says About In-Network and Out-of-Network Care
When to speak to a doctor
Never delay emergency care because of cost; call 911 or go to the emergency room for chest pain, trouble breathing, signs of stroke or severe injury. If cost is stopping you from getting care you need, talk with your doctor, pharmacist or the hospital billing office about options.
Where this comes from
- HealthCare.gov — Health insurance basics
- CMS — Summary of Benefits and Coverage
How this page was put together
Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.
Medical disclaimer
This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.
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