Cost sharing: a health insurance term

Cost-sharing refers to the patient’s portion of costs for healthcare services covered by their health insurance plan. A patient is responsible for paying cost-sharing amounts out-of-pocket. Cost-sharing can include a deductible, copayment, and/or coinsurance. Sometimes it’s a combination of all three. Cost-sharing is part of the benefits that you receive from your health plan.

Your health insurance plan will pay its cost-share for doctor and hospital visits, prescription drugs, wellness care, and medical devices. But there are some services that are not a part of cost sharing.

Are premiums part of cost-sharing? 

A premium is billed by your health insurance. It is when a policy holder pays for health coverage. A policyholder may be this cost alone or may split the cost with his or her employer. Policyholders must pay premiums each month, regardless of if they visit a doctor or use any other healthcare service. Premiums are out-of pocket expenses. But are not are not  part of cost- sharing. 

Types of Cost Sharing  

Copay — A fixed amount a person pays for qualifying types of services, such as office visits, specialist visits, prescription drugs or other procedures.  

For example, a member may have a $25 copay for an office visit with a primary care physician and a $40 copay for a specialist. All copays are fixed and detailed in the Summary or Schedule of Benefits (SOB) at the beginning of the plan. Copays can be charged before and/or after a person has reached his or her deductible. 

Deductible — The amount policyholders pay for covered services before the insurance company begins to pay. For example, if a member has a $2,000 deductible, that person will pay 100 percent of all eligible expenses until the bills total $2,000. Once the deductible is reached, the insurance carrier’s cost sharing changes. Some members may still be required to pay copays or coinsurance after reaching the deductible.  

See Also: an article on embedded vs non-embedded deductibles. 

Coinsurance — An amount paid after a person has met his or her deductible. It is a percentage of the allowed amount for services.  

For example, if a member has a 20% coinsurance on the plan, that person is responsible for 20% of the cost of any services. The insurance company will cover the rest.  

In practice, that works like this: The allowed amount for lab work is $100. If the member already met, or paid, the deductible, he or she will owe 20% of the allowed amount of $100, or $20. If the member has not met, or paid, the deductible, he or she will owe the full amount of $100.  

You may not have coinsurance, if you do not see it listed on your plan. Not all plans have coinsurance. 

Why cost sharing terms matter

It’s important you understand your benefits when you receive your plan documents. All health insurance plans come with a summary of benefits, which includes information on all copays, deductible and/or coinsurance. If you have additional questions about your plan, it’s best to contact the health insurance company directly. 

You may find contact information for the carrier on your member ID card. 

Finding a Primary Care Physician (PCP) can be overwhelming. Having someone who makes you feel comfortable is the first step to good communication about your health. Being proactive in your health care is important for the best outcomes.  

It is important to have a PCP, because he or she is responsible for screening all major health-related conditions. In most cases, that person knows your medical history and can recommend specialty physicians and additional care.   

What is a Primary Care Physician (PCP)? 

A Primary Care Physician will be the main point of contact for a patient’s basic medical needs, because that person can help recommend different treatment options.

There are different types of doctors that qualify as Primary Care Physicians. You could have a physician with the designation Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO) or a Nurse Practitioner (NP) listed as your PCP.  

Typically, these physicians are listed with the below specialties:  

• Family medicine 
• Pediatrician 
• Internal medicine  
• Geriatrics 

Search for a new PCP 

Ask friends, family or locals 

Asking for a recommendation from people you know is helpful. People often feel most comfortable visiting a physician who is recommended by someone they know, such as a family member.  

If you are moving to a new area, ask your current PCP if he or she can recommend a practice in the area. Once you have your PCP, he or she can refer you to specialty doctors.  

Search online  

Many patients find doctors by word of mouth, but now it is becoming more popular to find a new doctor online. Here are ways to research online for a new doctor. 

1. Use a search engine- using a search engine (like Google or Bing) is the first step to finding a new doctor. The most common search is finding doctors “near me.” The second highest search is looking up a provider’s profile listing. 
2. Look at online reviews- Looking at online reviews is a great way to learn more. You can use sites like Zocdoc and Healthgrades. These sites often show what types of insurance the facility accepts, how long the doctor has been practicing, and other information. Use any of that information to make your own judgements about the office. 

Check your primary carrier network 

It is important to see if the doctor you want to see is in-network. Each insurance carrier website has a tool to Find a Provider.  

This is where you can check if your doctor is designated as In Network. If you are having trouble, contact the carrier directly to be sure.  

We recommend all members check if their physician or facility is still listed as In Network before each appointment. Insurance networks can change at any time.  

RELATED POST: Avoid surprises on medical bills by preparing for visits

Request medical records 

Once you have decided on a new doctor, it is time to request your medical records. Your current office will send your records to your new office.  It is best to request your medical records before you schedule your first appointment. It is important to send your personal records so the office and doctor can be up to date with your medical care. 

The ClaimLinx office will be closed on Monday, September 4th to celebrate Labor Day. Our staff will be enjoying the last of the summer weather with friends and family. We hope all our clients and members can do the same.  

Our team members will respond to any calls or messages as soon as possible upon our return on Tuesday, September 5th. We appreciate your patience and understanding. 

Interesting facts about Labor Day 

• The first celebrated US Labor Day was on Tuesday, September 5, 1882, in New York City. It was planned by the Central Labor Union. 
• Labor Day is considered the ‘unofficial NFL season kickoff.’ Most years, the NFL plays its first official season game the Thursday after Labor Day. 
• On June 28, 1894, Congress passed an act making the first Monday in September of each year a legal holiday in the District of Columbia and the territories. 
• In July 2023, the American unemployment rate was 3.5%, which was equivalent to about 5.8 million unemployed Americans, according to the U.S. Bureau of Labor Statistics (BLS).   
• Millions of Americans are planning to travel over Labor Day weekend this year, according to The Vacationer, a travel news website. 

Fun activities to do over Labor Day Weekend  

• Host a sports tailgate- It’s finally football season! Host a tailgate party rooting for your favorite teams.  
• Take a Road Trip – The three-day weekend is the perfect time to take a road trip with family and friends. It is the perfect time to go visit and experience a new place.  
• Decorate Your Front Porch for Fall- Are you the person who decorates your house for fall? The long weekend is the perfect time to do it.  
• Give Back to Those Who work on Labor Day- Yes Labor Day is a national holiday, but many Americans work during the long weekend.  Let your kids make thank you cards for local law enforcement, firefighters, or other essential workers.  
• Go and watch a firework show- It’s not a summer holiday without fireworks. Find a good location and settle in for the show with your family and friends.