The Otsego County Chamber insurance plans are provided by multiple carriers providing benefit plans to our region. Each of these insurance companies develops products with participant cost sharing elements to balance benefits and premiums. Each company may assign a different cost share element to the same service, so reviewing the full plan summary is essential to knowing what exposures you may have for your cost share of the services provided. Below are descriptions of these different cost share elements of our plans.
Co-pay is essentially an encounter fee. Every time you encounter a service that has co-pay attached to it, you will pay that co-pay. Most services do not have a cap on the number of co-pays you may pay in a plan year. Also, co-pay does not reduce a deductible or co-insurance and does not accumulate to the out of pocket maximum for those two cost share elements.
Deductible is an amount that you pay before the insurance company pays anything. Some plans have certain services subject to the deductible. Other plans, like the HDHP have all services, other than preventive, subject to the deductible. A deductible is an annual amount that, when reached, is satisfied for the remainder of the plan year. The two different types of deductibles are embedded and aggregate.
Co-insurance is a percentage which you and the insurance company share for claims. Those services that are subject to the deductible are usually subject to co-insurance after the deductible has been satisfied. Like the deductible the co-insurance is an annual amount. Your co-insurance continues until you have satisfied the out of pocket maximum for the plan year.
Out of Pocket Maximum is an amount that limits your exposure for your cost sharing payments of copays, deductible and co-insurance to a set amount annually. This is often referred to as a stop loss amount. Keep in mind that co-pays and out of network balance billing does not accumulate to the out of pocket maximum.