Shared costs: what you pay and what your plan pays
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 your plan year begins, which is referred to as your effective date.
Phase 1: You pay (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 copayment before you meet your deductible. These copayments, also called copays, don’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 negotiated, lower price. When you pay in full for covered services or prescriptions, you pay the lower cost 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 cost 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. Preventive care is offered at no cost to you. You don't have to meet your deductible before receiving preventive care.
Phase 2: You pay some, your plan pays some
After you meet your deductible, your health plan begins to pay a share of the cost of covered medical services included in your plan.
During this cost-sharing phase, you pay your share of the 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.
Phase 3: 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 or anything listed in your plan documents as a covered benefit. See your plan documents in your member account for any exceptions.
Phase 3 continues until your plan year is up. Then you start over again in Phase 1 when your next plan year begins.