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What is Deductible

A deductible is the amount you pay for health care services before your health insurance begins to pay. Let’s say your plan’s deductible is $1,500. That means for most services, you’ll pay 100 percent of your medical and pharmacy bills until the amount you pay reaches $1,500. After that, you share the cost with your plan by paying coinsurance and copays.

What is Coinsurance

Coinsurance is your share of the costs of a health care service. It’s usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you’ve paid your plan’s deductible.

What is Copay

A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.

What is an out of pocket maximum

An out-of-pocket maximum is the most you’ll have to pay during a policy period (usually a year) for health care services. Once you’ve reached your out-of-pocket maximum, your plan begins to pay 100 percent of the allowed amount for covered services.

How do Deductible, Coinsurance, Copay and out of pocket maximum work?

All the money you pay toward your plan’s deductible, and for coinsurance and copays, go toward your out-of-pocket max. If you have a family plan—a plan that covers more than one person—your out-of-pocket max will be higher. But the coinsurance and copays you pay for everyone on the same policy all add up to the out-of-pocket max. For example, You have a plan that covers your wife and three children. Your out-of-pocket maximum is $10,200. Paying your $500 deductible goes toward your out-of-pocket max. Then your plan starts sharing the cost. Occasionally someone in the family gets sick and needs to go to the doctor. The copays and 20 percent coinsurance for that add up to another $700. That means Your paid $1,200 toward their out-of-pocket max. Then one of his kids breaks their leg badly. The hospital bills alone add up to about $40,000. There’s a lot of follow-up care needed, maybe even more surgery. But You won’t pay more than another $9,000 in copays and coinsurance because you will reach your out-of-pocket max. Then your plan pays 100 percent for all covered services.

What doesn't count toward your out-of-pocket max?

The monthly payments you make to maintain your health coverage and any charges for health care services your plan doesn’t cover.

What is HMO Plan

HMO stands for health maintenance organization. You pick one primary care physician(PCP). All your health care services go through that doctor. That means that you need a referral from your PCP before you can see any other health care professional, except in an emergency. Visits to health care professionals outside of your network typically aren’t covered by your insurance. One exception to this is that women don’t need a referral to see an obstetrician/gynecologist, or OB/GYN, in their network for routine services such as Pap tests, annual well-woman visits and obstetrical care.

What is PPO Plan

PPO stands for preferred provider organization. You don’t need a primary care physician. You can go to any health care professional you want without a referral—inside or outside of your network.

What is EPO Plan

EPO stands for exclusive provider organization. This plans combine the flexibility of PPO plans with the cost-savings of HMO plans. You won’t need to choose a primary care physician, and you don’t need referrals to see a specialist. But you’ll have a limited network of doctors and hospitals to choose from. And EPO plans don’t cover care outside your network unless it’s an emergency. It’s important to know who participates in your EPO plan’s network. If you go to a doctor or hospital that doesn’t accept your plan, you’ll pay all costs.

What is HSP Plan

HSP stands for Healthcare Service Plan.


JA Health Insurance Services
180 Grand Avenue, Suite 1530
Oakland, CA 94612
Ph: 1.800.400.6633