In-network vs. out-of-network benefits
In-network benefits consist of providers in a specific region that have agreed to a reduced rate of reimbursement from the insurance carrier. Many providers agree to this in-network rate reduction as they are likely to see greater patient volume. In-network benefits are likely to save you money.
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Out-of-network benefits consist of providers who have not agreed to this rate reduction offered by the insurance carrier. Your insurance plan may allow you to see providers out-of-network but it is likely you will spend more for your care.
Deductible vs. Co-pay vs. Co-insurance vs. Out-of-Pocket Maximum
Deductible is the amount you pay at the beginning of the year before your insurance covers any costs. Co-pays are excluded from this. ​
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Co-pay is a fixed amount you pay for a covered health care service. This must always be paid unless a plans out-of-pocket costs are satisfied. ​
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Out-of-pocket maximum is the highest amount of money you could spend on your healthcare during a single plan year before the insurance plan will cover 100% of remaining costs. This total maximum includes money spent on deductible, copays, and co-insurance.
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Co-insurance is the percentage of a claim an insured must pay after meeting their deductible.
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Example
Your plan:
Deductible= $2,000
Co-pay = $20 for PCP visit (Doctor vist)
Co-insurance = 80%/20%
Out-of-pocket maximum = $5,000
You go to the Doctors and your plan dictates that you have a $20 copay. You pay this amount up front before any services. Your plan has a $2,000 deductible. Once services are billed from the provider, you will pay the total amount of this bill and any other future bill until you have paid $2,000 out of your pocket. Many plans then have a co-insurance and your plans co-insurance is 80/20 meaning you will pay 20% of the claims after your deductible is met. Your plan also has an out of picket maximum of $5,000. If you continue to seek medical services, you will pay 20% of each bill until the plan year ends or until you have paid your plans maximum out of pocket costs. If you have met the $2,000 deductible + $5,000 out of pocket max ($7,000 total), you will no longer pay for medical services the rest of that plan year.
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