Paying for care before and after you meet your deductible
Here's a summary of what you pay for health care and what your plan pays over the course of a "plan year." Starting on the first day of your plan year (your "effective date"):
Phase ❶ You pay for (almost) everything
This phase is called "meeting your deductible."
When you have a deductible, you normally pay 100% of the cost of most covered medical services up to the amount of the deductible.
Some plans offer limited doctor visits and prescriptions for just a co-payment before you meet your deductible. These co-payments won't count towards your deductible.
Once all the claims you've paid in full for covered* medical services add up to the amount of your deductible, you have "met" your deductible and you move to Phase 2.
Good news during phase 1:
- You pay a discounted price. When you pay in full for covered* services or prescriptions, you pay the discounted rates that Priority Health negotiates with network physicians, hospitals, and pharmacies. That's why it pays to go to health care providers that are in your plan's network and show your ID card each time you visit the pharmacy.
- When you owe the full amount of a service, you usually don't have to pay it all up front. You may be asked to pay a part of the bill at the time of your visit. The doctor or hospital will send the bill or "claim" to Priority Health to learn the discount on it and have it counted against your deductible. Then they'll bill you for the balance.
- Preventive care exception Your plan pays 100% for physical exams, preventive vaccinations such as flu shots, mammograms and other covered preventive screenings and routine prenatal care. You don't have to meet your deductible first.
Phase ❷ You pay a share, your plan pays a share
After you meet your deductible, your health plan begins to pay a share of the cost of covered medical services.
During this cost-sharing phase you pay coinsurance. Coinsurance means you pay a percentage of covered health care costs, and your plan pays the rest - you pay 30% and the plan pays 70%, for example.
If you have an HSA, you probably skip Phase 2 and go from Phase 1 directly to ...
Phase ❸ Your plan pays for (almost) everything
Once your costs reach your "out-of-pocket limit," your plan begins to pay most costs.
Add together your deductible and all the copayments and coinsurance you've paid for covered health care costs. They can add up quickly if you're sick or need surgery. Good thing your plan has an out-of-pocket limit that sets the maximum amount you'll have to pay in any one plan year.
When your paid costs reach your out-of-pocket limit, the plan begins to pay 100% of the cost of covered services - almost. See your plan documents for any exceptions.
Phase 3 continues until your plan year is up. Then you start over in Phase 1.
See your personal plan costs now
You can see what you've paid toward your deductible, what your copayments and coinsurance are, and much more when you log in to your Priority Health member account.