St. Luke's Health Plan
July 17, 2022
Coinsurance (not to be confused with copay) is a set percentage you pay for medical costs after you meet your deductible. For example, let’s say you need an MRI that costs $7,000 and your coinsurance responsibility is 10 percent. You would pay $700 and your insurance would pay $6,300. Coinsurance can apply to many types of services, including prescriptions, tests, surgeries, and visits to a doctor—but remember, coinsurance won’t kick in until after you meet your deductible.
Like coinsurance, a copay is another way to share the costs between you and St. Luke’s Health Plan. Copays are flat fees paid directly to health care practitioners, such as your doctor or pharmacist. Depending on your plan, your copay may come into effect before or after you’ve met your deductible. Your copay might also differ based on the services you use—in other words, you might have a $10 copay on prescriptions, a $25 copay on specialists visits and a $100 copay for X-ray services. Be sure to check your plan for details so you’re not surprised by an unexpected expense.
Your deductible is the amount of money you’re responsible for before insurance picks up the remainder of the bill. For example, if you have a deductible of $5,000, you’ll pay out of pocket for all services and prescriptions until you reach your $5,000 maximum. Your deductible resets on a regular basis, usually at the start of the calendar year.
The process of joining an insurance plan is called enrollment. Once you or your employer have been set up for enrollment by St. Luke’s Health Plan, you’ll have a set amount of time to submit your information and choose a plan. This is called the enrollment period. After the enrollment period closes, you will officially be enrolled and your coverage will begin.
This special type of personal savings account lets you build up tax-free cash to pay toward health care expenses. A health savings account, or HSA, is completely under your control—you decide how much to contribute and where to spend your money. HSAs are especially useful for people who have high deductibles and long-term health care needs. The money in the HSA rolls over from year to year and is portable from job to job.
HSAs can help you save on taxes because your contributions are tax-free; however, you will be taxed if you choose to withdraw money for non-health care purchases. The federal government won’t allow you to use your HSA funds to pay your insurance premium.
If your deductible is high, you’ll share more of the up-front cost of insurance than you would with a low deductible. The IRS classifies a high deductible as more than $1,400 for an individual or $2,800 for a family. However, that doesn’t mean a high-deductible plan is a poor choice. High-deductible plans generally have lower premiums per month. People in good health and low-risk groups may safely opt for high-deductible plans to lower their overall health care costs. While high deductible plans are designed for individuals who rarely need health care services, from time to time we all have emergencies or may experience symptoms that may be signs of something more serious. Regardless of plan deductible, please seek care. Your health is most important.
Network refers to the group of health care professionals who are part of an insurance plan. These practitioners have worked with the insurance company to provide their services at a lower rate to plan members. With the St. Luke’s Health Plan, you’ll enjoy the most sought-after network in the state.
In network refers to doctors, pharmacists and other health care practitioners who have negotiated a discounted price for the service you are receiving with your insurance plan. It’s a good idea to stick to in-network care if you would like to reduce your costs. Some plans, such as St. Luke’s Health Plan, do not charge for referrals or pharmacist charges for in-network practitioners so it is easier for you get your care in network and save money. In-network practitioners also cannot bill you for any amount over the agreed upon price, where out-of-network practitioners can bill at a rate of their choice.
Health care practitioners who are not part of an insurance plan are out-of-network. As a member of an insurance plan, you are still welcome to use their services—however, you will pay more out of your own pocket to do so because the price is set by the practitioner. There is no agreement with your insurance company on a fixed price, so your insurance will cover the portion they agreed to pay for out-of-network costs and you will be responsible for the remaining amount that the practitioner has charged.
The out-of-pocket maximum (also known as the out-of-pocket limit) is the most you will pay toward your health care costs in a calendar year. These costs can include your deductible, copayments and coinsurance costs. Your maximum does not include costs to use out-of-network doctors, monthly premiums or services that aren’t covered by your plan—even if they are health care services.