06/09/2026
Why does the "Expectation vs. Reality" happen when it comes to health insurance?
Many people believe that having health insurance means the insurance company pays the entire bill. In reality, most health plans require you to share in the cost of your care.
Deductible: This is the amount you must pay for covered medical expenses before your insurance begins paying its share. For example, if your deductible is $5,000, you'll generally pay the first $5,000 of covered expenses yourself before the plan starts contributing.
Copays: These are fixed amounts you pay for certain services, such as a doctor visit, urgent care visit, or prescription medication. A copay might be $30 for a primary care visit or $75 for urgent care.
Coinsurance: Even after you've met your deductible, many plans still require you to pay a percentage of the cost. For example, if your plan has 20% coinsurance, insurance may pay 80% while you pay the remaining 20% until you reach your out-of-pocket maximum.
🚩 A common surprise: Some plans have separate ER or hospital copays. This means that even after you've met your deductible, you could still owe a specific copay for an emergency room visit or hospital admission, depending on your plan's design.
Health insurance can provide tremendous financial protection, but understanding how your deductible, copays, coinsurance, and out-of-pocket maximum work together is important. A few minutes reviewing your benefits today can help prevent expensive surprises later.
If you'd like help understanding your current coverage, send me a message.
