Open enrollment comes around every year, and every year patients ask us the same thing: how do I tell whether a plan is any good? So here is a plain-English explanation of what the terms mean, and how to actually compare plans.
The terms, decoded
- Premium. What you pay every month to keep coverage active, whether you use it or not.
- Co-pay. The flat amount you hand over at the front desk. Primary care co-pays commonly run around $20–40; urgent care is often higher, in the $50–100 range. This is not the total cost of your visit. It is just what you pay that day.
- Co-insurance. The percentage of a covered bill you pay after your deductible is met — usually 20% or 30%. That is what “80/20” or “70/30” means: on an 80/20 plan, insurance pays 80% of a covered $100 bill and you pay $20.
- Deductible. What you must pay out of your own pocket before your insurance starts paying anything. If your deductible is $5,000, you pay the first $5,000.
- Maximum out of pocket. The most you will pay for covered care in a year. It counts your co-pays, deductible and co-insurance — it does not count your premium.
What that looks like in real life
Say you buy an 80/20 plan with a $200 monthly premium, $20 primary care co-pays, $50 urgent care co-pays, a $6,000 deductible and a $7,000 maximum out of pocket.
You get a sinus infection and come see us. You pay your $20 co-pay at the desk. Then we bill your insurance $120 for the visit — but because you haven’t met any of your $6,000 deductible yet, that $120 comes back to you. Your sinus infection cost $140, not $20. At an urgent care with a $50 co-pay, it would be $170.
Now say you’d already had a car accident that year and paid $6,000 toward hospital bills. Your deductible is met, so your 80/20 coverage kicks in and that same $120 visit costs you about $24 — until you hit your $7,000 maximum out of pocket, after which covered care costs you nothing more that year.
And now you can see why health care feels so expensive.
How to choose
- Call your provider’s office first and ask which plans they are contracted with. This is the step people skip. Pick a plan, then discover your doctor is out of network, and you are stuck for a year. (You can see the plans we accept on our Insurance & Billing page — and networks change, so it is always worth a phone call.)
- Low premium usually means high deductible, and vice versa. You are choosing when to pay, not whether.
- If you rarely see a provider, a high-deductible plan can make sense and save you real money on premiums — as long as you can absorb the deductible if something goes wrong. That is the trade you are accepting.
- Check whether the plan covers what you actually use — your prescriptions, your specialists, the hospital you would want to use.
A word about “health sharing” plans
You will run into health care sharing ministries advertised as an affordable alternative to insurance. We used to mention them here as an option, and we want to be straight with you about why we no longer do.
They are not insurance. They are generally not regulated by state insurance departments, they are not required to pay your claims, and the consumer protections you get with a real insurance plan — guaranteed coverage for pre-existing conditions, essential health benefits, an appeals process — do not apply. The National Association of Insurance Commissioners and more than a dozen states have issued consumer alerts about them, and several have collapsed or faced legal action leaving members with large unpaid medical bills.
Some people do use them and are satisfied. But if you are considering one, go in knowing that a “shared” bill is a request, not a guarantee — and that if it isn’t paid, the bill is yours.
If you don’t have insurance
You can still be seen here. Our self-pay rates are simple and posted on our Insurance & Billing page, along with the plans we accept and current pricing for labs and imaging. No membership, no surprises — and we will tell you what something costs before we do it.
Still confused?
Insurance is a genuinely difficult hoop to jump through, and nobody should feel silly for finding it confusing. Ask your health care provider — and if we don’t know the answer, we will help you find someone who does. Call us at (417) 332-3639 or send us a message.
As always, I hope you stay happy and healthy.
Carolyn Clark, NP-C