– Healthcare Plans in the US


I am a 25 year old man who spent his 18-now in the military with tricare. I now have a job where I have to enroll in healthcare. What do I look for in a plan? What is a deductible? If I have a co-pay, do I still have to pay up to $8000 just to GET to my co-pay? Why did no one explain this to me?

In: 4

You have to read through the insurance, but in general a co-pay is for doctor visits. It is separate from the deductible. The deductible is for any actual service you need. So if you break your leg, you pay 8k then insurance pays after that, whatever the percentage is. Insurance is complicated in the USA, which is awesome for the insurance companies, not so much for the average person though.

Look for the plan that you think is going to cover what you think you will need. It is a guessing game though.

Different plans have different benefits. Premiums are what you pay on a monthly basis regardless of what you use – generally speaking higher premium means a lower deductible and maximum out of pocket cost.

A deductible is how much you have to pay before you insurance starts covering things, and a max out of pocket cost is how much you pay before they cover everything for the rest of the year.

Another thing to consider is that in-network and out-network are different things. In-network providers are the preferred health systems where your insurance provider has some negotiated deal with, out-network providers are ones where they haven’t done that. So you’d be able to meet your max out of pocket cost for in-network but if you had to use out-network care systems you’d need to start meeting that goal before they’d cover it.

Also FSAs and HSAs exist. An FSA is a flex spending account, when you sign up for insurance you’re able to opt to put in x amount of pre-tax money towards this if you know you’re going to hit your out of pocket max for the year. The downside to FSAs is that the money *has* to be used by the end of the year or it disappears. You can use it for all sorts of things though, and there are specific FSA lists of stuff you can buy. If I ever have any left, I rarely do, I just buy a bunch of stuff that I can donate like period products and give them to local charities.

HSAs are health savings accounts. This is a similar idea, but unused money instead gets moved into a, you guess its, savings account where if you need to spend a larger amount of money at a single time you have access to it.

E: Oh yeah copays are a thing too, I don’t really have them so I forget about them. Co-pays are fees that are due at time of service (checking in for an appointment). They usually range from between $10~75, though that higher end seems a lot less common.

I’ll take the easiest 1 first:

> If I have a co-pay, do I still have to pay up to $8000 just to GET to my co-pay?


you haven’t provided enough info on whatever plan(s) you’re looking at to state unequivocally, but that $8k amount sounds like the maximum amount you might pay out of your own pocket in a year before the plan pays all of your covered medical treatment charges over that amount. It feels likely that if for example you were to visit your doctor for a routine physical, you’d pay some kind of copay – $20, let’s say – without having to satisfy any *deductible* amount, or perhaps after paying for covered charges that total to as much or more than that deductible. All of that information should be available to you at a website displayed on your ID card, or in email you’ve received about your coverage, etc.


>Why did no one explain this to me?

one or more representatives of your employer seems to have let you down.

Have you asked your supervisor who in your company is responsible for fielding questions about HR/benefitssubjects? If not, why not?

Unironically, watch this [video](https://youtu.be/-wpHszfnJns). It helped me when I turned 26 this year and aged out.

You’ll have to see what what your employer offers and what your needs are and find a good fit. You’ll have to weight how much you are making versus and chronic illnesses you have, medication, dependents, etc. I’m sorry but this a personal choice that you will know best to make.

When it comes to health insurance, and what is covered, and what is not covered, and what you have to pay out of pocket, you should always, always always call the health insurance company / plan coordinator and ask them. There can be lots of fine print that can change things and you want to know exactly how you plan works, and they can tell you

In general:

Deductible: Amount you have to pay before benefits kick in

Co-pay: A percent of a bill that you pay, insurance covers the rest

Annual out of pocket max: The most you can pay per year, after this insurance covers 100%

Again, these are GENERAL descriptions, ALWAYS call your plan coordinator and ask them exactly how their plan works. The last thing you want is to end up with some huge amount of medical debt because you thought our benefits worked one way and they actually work another.