A lot of people get mixed up in insurance terminology, so I am going to break it down in the hope that it helps someone.
Premium - The premium simply put is the amount that you, must pay every month in order to keep your insurance.
Co-pay - This is an amount you pay your provider directly for an office visit and / or a procedure. Some insurances break down every little thing into a different copay amount, for example, say you see your doctor for a basic office visit, and that doctor takes a documentary photo, and does a pachemetry to check your corneal thickness. The office exam copay could be $30, the photo copay could be $20, and the pachemetry copay could be another $20. so that is $70 due on the day of service for the copays.
Co-Insurance - Co-insurance is a percentage of the insurances allowable amount that you are expected to pay. Co-insurances usually apply when your deductible has been met, and are almost always billed to you after the fact. They are billed to you after the fact because insurances all follow different "fee schedules" and for the most part we simply don't know how much your co-insurance will be for the visit. For example, You have a 20% co-insurance, you have met your deductible for the year and have an office visit. Your insurance was billed for $150, but they allow $96.40 in accordance with their fee schedule. Your insurance will then pay us $77.12, and you are expected to pay the additional $15.28 so the provider gets the full $96.40 that your insurance allows.
Deductible - The deductible is an amount usually annually that you must meet out of pocket before your insurance will pay a provider. Most of the time the deductible applies to all of your insurance benefits, but sometimes it applies to individual benefits such as prescription medication or surgeries. Most of what you pay your provider out of pocket will be applied toward your deductible, except copays and coinsurance. Your provider will bill you for the deductible amount after the exam. For example, you have not yet met your deductible, and had an office visit. Your insurance was billed for $150, but they allow $96.40 in accordance with their fee schedule, and they applied it toward your deductible, the insurance pays your doctor nothing. The doctors office then bills you for that $96.40.
Out of Pocket Max - The out of pocket max is in addition to your deductible, this is the amount that you must pay in order for your insurance to pick up the entire bill. Everything you pay your provider will be applied toward your out of pocket max including deductible amounts, co-insurance, copays, etc. The only thing you pay that will not be applied toward this is your monthly premiums.
I hope you enjoyed this quick breakdown on some of the more common insurance terms and the examples provided. I know no one likes getting a random bill in the mail, I know we don't like to send them, but hopefully this makes some of the jargin a little bit easier to understand.
Thank you,
Justin Amyot
Vision Haus Co-Manager