Deductible: In general, the higher the deductible, the lower the monthly premium and the lower the deductible, the higher the monthly premium. The deductible is solely your responsibility and must be paid first before the insurance carrier will begin to pay their portion of any major medical claims. You may be asked to pay your deductible before admitted into a hospital or before a surgical procedure can be completed.

Out of Pocket: Your out of pocket is the dollar amount of your responsibility beyond the deductible. Some insurance carriers express their out of pocket as inclusive of your deductible and some do not include the deductible.

For example, a plan that pays 100% after a $5,000 deductible is hit can be expressed as having a $5,000 total out of pocket.
Another example would include a plan that has an additional $2,000 out of pocket after the $5,000 deductible is hit. This would result in a total out of pocket of $7,000.

Before choosing a plan, make sure to analyze your risk and corresponding monthly premium based on the total out of pocket, including deductible.

Co Pays: Your copay will be a fixed dollar amount that you will pay for certain services (such as a routine office visit) or for a prescription at the pharmacy. A copay for an office visit generally does not require you to hit your major medical deductible first. The opposite is true for prescriptions. Most private Texas health insurance policies have a prescription deductible that must be hit first before the co pays apply.

Lab/Xray: For most private health insurance plans, lab/xray will generally be subject to your deductible and is not included with the co pay for the office visit. You would normally receive the PPO contracted rate on the services and whatever you spend will count toward the deductible of your health plan.

Preventive Care: Due to recent healthcare reform, preventive care is normally covered at 100% with no co pays required. This would include 1) a routine, annual physical including blood work for all adults 2) a routine, annual pap smear for all women 2) a routine annual mammogram for all women over the age 35 and over 4) a routine colonoscopy for all adults age 50 and over and 5) routine well baby/child checks including immunizations.

Make sure to analyze all benefits as compared to monthly premium before deciding which plan would best fir your needs. As always, if you need help making your decision, please contact or call us at 866.270.6209.