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What Is The Difference Between Co-Insurance And Co-Payments?

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For more information about the Affordable Care Act, visit CBSChicago.com/ACA.

Co-insurance and co-payments are different forms of cost sharing. You are sharing the cost of your health care with your health insurance company. In addition to co-payments and co-insurance, most policyholders can expect to pay a deductible before their health plan provides any benefits. When shopping for a health plan in the health insurance marketplace, you will be able to compare the cost-sharing requirements of each plan. As a general rule, premiums will be lower on plans that require you share a larger part of your health care costs.

Co-Payments Basics

A co-payment, or co-pay, is a set amount you must pay for a particular service. The amount may vary for different services. For example, your health plan may require a $35 co-pay for a doctor visit, a $10 co-pay to have a prescription filled and a $200 co-pay for outpatient surgery.

Co-Insurance Basics

Co-insurance is the percentage of the medical bill you are required to pay after meeting any deductible. For example, if you plan’s medical deductible is $850 a year with 10-percent coinsurance, you will pay the first $850 in medical expenses out-of-pocket. After meeting the deductible, you will only be responsible for 10 percent of any new charges. A $150 doctor visit will cost you $15.

Health Plan Services Covered at No Cost

The Affordable Care Act (ACA) requires that all health plans cover certain preventive health services without charging a co-payment or co-insurance. These services include health screenings, vaccinations and reproductive health services for women. You will not be charged for these services if you use a provider in your health plan’s network.

Health Insurance Exchange Metal Levels Explained

Health plans offered in the health insurance marketplace are assigned metal levels: Bronze, Silver, Gold and Platinum. All plans must include the 10 essential health benefits. The difference is in the cost-sharing requirements. The more valuable the metal — Platinum is the most precious — the higher the premium and the lower the cost sharing to policyholders.

The idea behind the metal levels is to provide apple-to-apple comparisons when policy shopping. The least expensive plans are in the Bronze category. You can expect to pay 40 percent of your health care costs in deductibles, co-pays and co-insurance when purchasing a policy at this level. Cost sharing with Silver plans is, on average, 30 percent of total health care costs, Gold plans average 20 percent and Platinum 10 percent.

These percentages should not be confused with co-insurance percentages. The metal levels are just a way of lining up policies with comparable cost-sharing requirements to assist consumers shopping for health insurance.

Gillian Burdett is a freelance writer covering all things home and living. Her work can be found on Examiner.com.

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