How Health Plans Work
Costs, benefits, savings, deductibles. Watch 3 short videos and understand your healthcare better.
3 things to know
Health plan basics: Benefits
Benefits are health products and services your plan covers—subject to copay, coinsurance, or deductible. Services include emergency care, pregnancy, mental health, prescription medication, and more. To see your specific plan’s benefits, sign into your account and review your summary of benefits and coverage. You can also contact LifeWise customer service or ask your broker for more information.
Sign in for all benefits
How your health plan works
Health plan basics: Costs
When you buy something at a store, you know exactly how much it costs when you leave. Unfortunately, healthcare doesn’t work quite like that. Your costs include the monthly premium. When you receive care or pick up medication, you might also pay a deductible, and copay or coinsurance. The video explains more.
Let’s say your health plan has:
$2,500 deductible
For in-network services
$35 copay
For office visits
30%
Coinsurance
$6,350
Out-of-pocket maximum
Here’s another example of how health plan costs work
You pay for most care and medical services until you’ve met your deductible of $2,500. For each office visit, you pay a $35 copay whether or not you’ve met your deductible.
After you’ve paid your $2,500 deductible for the plan year, your plan starts paying 70 percent of the cost of covered care. You pay 30 percent, which is your coinsurance. For example, if the total cost of an office visit was $200, you’d pay $60 coinsurance ($200 x .30 = $60). Your plan would pay $140 ($200 x .70 = $140). For an office visit, you’d also pay a $35 copay.
After you’ve paid $6,350 in your deductible, copays, and coinsurance, you’ve met your out-of-pocket maximum. Your plan pays 100 percent of your covered care for the rest of the plan year as long as you use in-network providers.
Note: These are example numbers. Please look at your plan benefit booklet for your exact deductible, coinsurance, copay, out-of-pocket maximum, and other information on amounts you’re required to pay. You can also search your specific provider network.
Health savings account (HSA) basics
A health savings account (HSA) is like a bank account for your healthcare expenses. You can tuck money aside pre-tax. The money can be used to pay for your out-of-pocket costs at the doctor’s office or pharmacy. You can also use it to pay for eligible items like glasses, first-aid items, and family planning supplies. The money is yours, so if you don’t use it, it keeps growing.
Definitions
Allowed amount
This is the amount providers have agreed to accept as full payment for covered healthcare services and supplies. It’s important to use an in-network provider. Otherwise, out-of-network providers can bill the difference between the rate LifeWise would pay an in-network provider for the service and what the provider billed. The remaining balance, which is the patient’s responsibility, is called balance billing.
Coinsurance
The percentage of healthcare costs you’re responsible for. After you meet the deductible, you and LifeWise will share the cost of care until you’ve reached the out-of-pocket maximum. For example, if you have 20 percent coinsurance, your health plan would pay 80 percent of the bill and you would be responsible for the remaining 20 percent until your out-of-pocket maximum is reached.
Copay
Similar to coinsurance, but it’s a fixed amount paid at the time of service rather than a percentage of the cost. If you have a $50 copay, you’d pay $50 at your doctor visit.
Covered
Your health plan offers payment for a service, although not necessarily at 100 percent. The cost is subject to copay, deductible, network, and plan limits.
Deductible
The amount you pay for covered health care services in a plan year before your health plan starts to contribute to your cost of care. With a $2,000 deductible, for example, you pay the first $2,000 of covered services.
Out-of-pocket maximum
When the amount you’ve spent on deductible and copay or coinsurance meets your out-of-pocket maximum amount, your health plan will pay for your eligible medical expenses for the rest of the plan year. This is the most you’ll have to pay out of pocket for your covered care. Your monthly premiums do not count toward your out-of-pocket maximum.
Premium
The monthly payment you or your employer pay for your health coverage. This is what you pay to have medical coverage. The amount doesn’t count toward your deductible or out-of-pocket maximum.
Frequently asked questions
How do I find doctors in my network?
Sign in to your online account and use Find Care to get personalized results, including providers in your network.
Sign in to search your network
If you do not sign in, you can use Find Care, and select the network yourself. Get the name of your network from the front of your member card.
What happens if I use an out-of-network provider?
Out-of-network providers can charge additional amounts for services that don’t apply to your annual out-of-pocket maximum. This could mean the service will cost more or not be paid for at all by LifeWise.
For example, if you have a procedure with an in-network provider who usually charges $200, but the allowed plan amount is $150, they can only charge $150. The doctor writes off the other $50. If you have the same procedure withan out-of-network provider, the provider can bill you the additional $50. If your LifeWise plan has out-of-network benefits, it will only cover the allowed amount that they would pay a contracted provider.