July 24, 2019
Cost sharing is when both you and your medical plan pay for your health care expenses. Your deductible, coinsurance and copays are all out-of-pocket expenses that you are responsible for, but the way that each one works and functions is different.
A deductible is the amount that you pay for your health care before your SmartHealth medical plan begins to pay. Where you receive care (Ascension Network, National Network and out-of-network) determines not only the amount of your deductible but also the cost of your care. Receiving medical care from Ascension Network Tier 1 providers assures you have the lowest deductibles and the best negotiated rates for your care. For example, if you were to seek care without insurance, the charge for the service rendered may be $100, but your health plan may have a negotiated rate of $70 for that service. You will be responsible for paying that lower negotiated rate of $70. Keep in mind, if you choose to go to a Tier 2 provider your deductible may be higher and in addition to a higher deductible if you use and out -of-network, Tier 3, provider there likely won’t be a lower negotiated rate available, meaning your costs will likely be much higher. Once your deductible is met, then your health plan begins to share the cost of your expenses through coinsurance.
Coinsurance kicks in after your deductible is met and both you and the SmartHealth medical plan pay a percentage of the cost of the service. For example, if your coinsurance is 15 percent, you will pay 15 percent of the cost of the service while SmartHealth will pay the other 85 percent of the cost. This means that a $1000 procedure would only cost you $150 and SmartHealth would pay the other $850. You will continue to share the cost of your care until your out-of-pocket maximum is reached. Remember, just like your deductible, the amount of your coinsurance and out-of-pocket maximum is different depending on where you receive care. Ascension Network Tier 1 providers have the lowest member coinsurance and costs for care.
Copays are a fixed amount that you pay for a service—typically physician office visits, urgent care visits and emergency visits. Copays do not count toward your deductible, and frequently are applied after your deductible has been met. The copay amount can vary by the type of service.
Like deductibles and coinsurance, copays are lower if you’re utilizing Tier 1 (Ascension Network) and higher if you’re using either Tier 2 (National Network) or Tier 3 (Out-of-Network.) For example, an urgent care visit may be a $50 copay for a Tier 1 provider but have a $60 copay if you visit a Tier 2 provider.
SmartHealth plans also have an out-of-pocket maximum, which is the most that you could pay for covered medical expenses in a year. This amount includes your deductibles, coinsurance and copays. Once you reach your out-of-pocket maximum, your health plan will pay the rest of the covered medical expenses for the remainder of the year.
Please keep in mind that this article is for educational purposes, and is not an official plan document. To find out more information about the specifics of your plan, please visit www.mysmarthealth.org and read your schedule of benefits and Summary Plan Description.