top of page

Decoding Healthcare Plans: A Guide for 6th Graders (and Confused Adults)

Student teacher thumbs up

Whether you have Aetna, United Healthcare, Kaiser Permanente of Northern California, Anthem Blue Cross, and Anthem Blue Shield - there are some common terms that almost all of us find both nauseating and confusing. We couldn't agree more (and we do this for our jobs). Hang in there though, today we're on a mission to unravel the mysteries of copays, coinsurance, deductibles, and out-of-pocket maximums. So, grab your adventurer's hat, and let's dive into this journey together!

Deductible: The Magic Number

Now, the deductible is a bit like a magic number in your healthcare story. It's the amount you have to spend on covered services before your insurance really kicks in. If your deductible is $500, you pay for the full cost of healthcare visits until you reach that amount. After that, your insurance starts helping out more. Quick note, sometimes deductibles don't apply to mental health services - so check your plan (or ask us). If your deductible doesn't apply your copay or coninsurance start from the beginning for mental health services, but you have to meet the deductible for other medical services.

Copay: Your Health Ticket

Let's talk about copays – think of them as the entrance fee to your health adventure. After the deductible is met, when you visit the doctor, you pay a small, fixed amount, like a ticket for a ride at the amusement park. For example, if your copay is $20, that's what you give the friendly receptionist when you check in. Easy, right?

Coinsurance: Teaming Up with Insurance

Now, coinsurance is like having a healthcare buddy - you and your insurance share the cost of your care after the copay. Let's say you have 20% coinsurance. If your doctor bill is $100, you pay $20, and your insurance covers the rest. It's like splitting a pizza with a friend – you each chip in.

Out-of-Pocket Maximum: Your Safety Net

The out-of-pocket maximum is like the net under the trapeze artist. Once you've spent a certain amount in copays, coninsurance, and deductibles during the year – let's say $1,000 – your insurance takes over and covers everything at 100%. So, it's like a financial safety net that says, "Relax, we've got you covered now." Any services received after this are generally 100% covered at no cost to you.

Examples for Decoding Healthcare Plans:

Now, let's put all this into a story using our friends from Optum, Aetna, United Healthcare, Kaiser Permanente of Northern California, Anthem Blue Cross, and Anthem Blue Shield.

United Healthcare's Dr. Deductible:

- Let's say your United Healthcare plan has a deductible of $750. You pay the full cost of healthcare visits until you've paid that amount. After that, United Healthcare becomes your healthcare hero, helping you out more by only charging you for copays and/or coinsurance.

Optum's Copay Quest:

- If you visit Optum land and your copay is $25. You pay that when you arrive, just like a ticket to a fantastic healthcare them park (think Disneyland for healthcare where you wait in line except instead of Space Mountain you get a shot - exciting right?!).

Aetna's Coinsurance Chronicles:

- Now, Aetna steps in with its sidekick, coinsurance. Let's say you have 10% coinsurance. You pay 10% of the remaining cost (after the copay) of the service and Aetna pays the other 90%. So if the service was $100 and you had 10% coinsurance and a $10 copay, you'd pay the $10 copay and then 10% of the remaining $90 (that would be $9) - for a total of $19. It's like coming home after an epic road trip and having someone there to clean out your car and wash your clothes for you.

Kaiser Permanente's Out-of-Pocket Odyssey:

- Picture yourself on an odyssey with Kaiser Permanente of Northern California. Your out-of-pocket maximum is $2,000. Once you've spent that much (in deductibles, copays, and coinsurance), Kaiser Permanente takes the reins and covers everything – a financial superhero to the rescue!


There you have it, young healthcare adventurers! Copays, coinsurance, deductibles, and out-of-pocket maximums are like the secret code to unlocking the mysteries of health insurance and understanding what you can expect to pay. Next time you get a bill, remember our journey together through the healthcare jungle. You are offically prepared to begin decoding healthcare plans on your own. And hey, don't forget your adventurer's hat! If you are still confused or are just too overwhelmed to try and figure it out, no worries! We have some team members that would love nothing more than to get you the answers. Contact us today!

26 views0 comments


Commenting has been turned off.
bottom of page