You're Enrolled. Now What?
A simple guide to using your plan. We'll explain the 4 key terms, what happens when you get care, and how to read your bill.
The 4 Terms That Define Your Costs
These four terms work together. Think of them as steps.
1. Deductible
This is the fixed amount you must pay first, out-of-pocket, each year *before* your insurance starts to pay its share.
(Most plans cover preventive care like checkups 100%, even before you meet your deductible.)
2. Co-pay
A flat fee you pay for a specific service, like a doctor's visit or a prescription.
On many plans, you pay this *instead* of paying toward your deductible for that visit. On other plans, you pay this *after* your deductible is met.
3. Co-insurance
This is the percentage of the bill you share with your plan *after* you’ve met your deductible.
Example: For an 80/20 plan, your insurer pays 80%, and you pay 20%.
4. Out-of-Pocket Max
This is the absolute most you will pay for covered, in-network care in a year.
Once you hit this number (from your deductible + co-pays + co-insurance), your plan pays 100% of covered costs for the rest of the year.
Real-World Scenario: You Break Your Leg
Let's see how this works. Imagine your plan has a $3,000 Deductible, 20% Co-insurance, and a $6,000 Out-of-Pocket Max.
Your ER visit and surgery result in a $10,000 final bill.
Step 1: You pay your Deductible.
You pay the first $3,000 of the bill. This satisfies your deductible.
Remaining Bill: $7,000
Step 2: You pay your Co-insurance.
Now your 20% co-insurance kicks in on the remaining $7,000.
You pay: 20% of $7,000 = $1,400.
Your plan pays: 80% of $7,000 = $5,600.
Step 3: You are done.
Your total cost for the $10,000 bill is:
$3,000 (Deductible) + $1,400 (Co-insurance) = $4,400
You did not hit your $6,000 Out-of-Pocket Max. If you have more medical bills this year, you only have $1,600 left to pay ($6,000 Max - $4,400 Paid) before your plan pays 100%.
Other Key Parts of Your Plan
Mental Health Coverage
Under the ACA, mental and behavioral health services are an Essential Health Benefit. This means all marketplace plans *must* cover them.
The Mental Health Parity law also means plans can't have more restrictive limits on mental health care than they do for physical health care (e.g., they can't limit therapy visits if they don't limit specialist visits).
Action: Look in your plan documents for "Behavioral Health" to find your co-pay for in-network therapists and psychiatrists.
How to Read an EOB
That "Explanation of Benefits" you get in the mail is NOT A BILL. It's a receipt from your insurer.
What to check:
- Amount Billed: What the doctor charged.
- Plan Discount: The "negotiated rate" your plan has.
- Plan Paid: What your insurer paid.
- Amount You Owe: This is the number to watch. Wait until you get an *actual bill* from your doctor, and make sure it matches this number.
It Can Still Be Confusing. We Can Help.
Knowing these terms is the first step. If you get a bill that doesn't make sense or need help finding a plan that fits your life, SRA Healthcare is here to translate.
Ask an SRA Agent