Understanding Cost Sharing: What You Pay
Jot down information about your health plan and cost-sharing below. Use your insurance policy or certificate, your insurance card, your Schedule of Benefits/Outline of Coverage, and/or your SBC to find the information.
Keep reading to understand what the different terms mean and how your costs are calculated.
Deductible: The amount of money you must spend each year on your health care before your plan starts to pay.
If family members are covered under your health plan, there will be two deductibles. Once you’ve met the family deductible, you’ve also met the individual deductible. Your plan may pay for some preventive services, like an annual physical, even if you haven’t met your deductible. You may have a separate deductible for prescription drugs.
Your Deductible (Individual):
Your Deductible (Family):
Prescription Drug (Rx) Deductible:
Included in the deductible above
Not included in the deductible above
Your Rx Deductible (Individual):
Rx Deductible (Family):
Co-Pay: A fixed fee you pay directly to the provider when you get health care (for example, $40 for every primary care visit).
Your Co-Pays:
In-network Primary Care:
Out-of-network Primary Care:
In-network Specialist:
Out-of-network Specialist:
In-network Emergency Department:
Out-of-network Emergency Department:
In-network Urgent Care:
Out-of-network Urgent Care:
Prescription:
Coinsurance: A percentage you pay for most health care even after you meet your deductible. For example, if your coinsurance is 20%, then the insurer pays 80% of the covered amount and you pay 20% until you reach your out-of-pocket maximum.
Your Coinsurance:
In-network:
Out-of-network:
Out-of-Pocket Maximum: The most you pay during a plan period before your health plan pays all of the costs for covered services. This maximum doesn’t include your monthly premium.
My Out-of-Pocket Maximum:
Family Out-of-Pocket Maximum:
Monthly Premium: A fixed amount that you pay each month or with each paycheck for your health plan. If you miss payments or pay late, the insurer could cancel your plan.
Your Monthly Premium:
How you and your Health Plan share costs - EXAMPLE
Jane's Plan:
Deductible: $1,500
Co-Pay: $0
Coinsurance: 20%
Out-of-Pocket Maximum: $5,000
Get free help with your health coverage!
The Maryland Insurance Administration has a Health Coverage Assistance Team (H-CAT) to assist consumers. If you have questions or concerns about health coverage for you or your loved ones, the H-CAT staff is here for you.
- Get answers to your health insurance questions.
- Address health insurance problems or concerns.
- File a complaint about your health insurance issue or concern.
- Connect you to resources.
Phone: 410-468-2442
