Your insurance plan is a cost-sharing agreement between you and your insurance company. Generally, many insurance companies cover the costs for preventive care throughout the year, such as check-ups, vaccinations, etc.
For other services, many insurance companies require you to cover all costs until you reach a specified amount—known as a deductible. Once you reach that specific amount, then the insurance company starts paying for covered services.
For example, if you have a $500 deductible, then every year you will have to pay your medical costs for non-preventive care until you have paid a total of $500. Once you reach that $500 limit, the insurance company will begin to cover some of your medical costs for the rest of the year.
How much they pay for each procedure and service after you’ve reached your deductible depends on your particular plan.
After you receive care at Northwell, we send a bill to your insurance company. They then determine how much they will pay for a service or visit, and how much you are responsible for (this breakdown is shown on the Explanation of Benefits, or EOB, provided by the insurance company).
Once Northwell receives this information from the insurance company, we send a bill for the amount you owe – this is your patient responsibility. If you have questions about what and how much was covered by your insurance company, you should contact them directly.
Other key insurance terms
Here are other key insurance terms to help you understand your coverage and responsibilities for costs associated with your care:
A copay (short for copayment) is a fixed dollar amount that you pay every time you receive medical care.
For example, if you have a $20 copay, you will need to pay $20 to the provider’s office when you go in for your doctor’s appointment. Many plans have different copay amounts for different services. So your copay may be $20 for a checkup but $50 for a visit to an urgent care center.
A deductible is a fixed dollar amount that you need to pay within a defined period of time (such as one calendar or plan year) before your insurer will start to cover some of the costs for covered medical services.
Coinsurance is another way you may be required to share costs with your insurance provider. With coinsurance, instead of paying a fixed amount each time you receive medical care, you may be required to pay a percentage of the total costs. For example, your insurance company may pay 80% of the cost, and you may be responsible for to pay for the remaining 20% of the bill.
A maximum out-of-pocket (MOOP) expense is the most you’ll have to pay for your medical costs in a given time period, usually one calendar year or one plan year.
Here’s an example: Let’s say you have an insurance plan with a $4,000 MOOP. This year, you’ve had doctors’ appointments and an emergency room visit. You paid your copays, and you also paid your $400 deductible and $3,600 in coinsurance. Once you’ve paid $4,000, your insurance company will cover 100% of your medical expenses for the remainder of the plan year.