2023 Benefits Guide Benefit Definitions What is a premium? A premium (also referred to as a contribution) is the What counts toward my out-of- monthly cost you pay for health insurance, whether you pocket maximum? use medical services or not. Premiums are deducted directly from your paycheck. An out-of-pocket maximum is an annual cap on the dollar amount you are expected to pay out of your What is a deductible? own pocket for services (including deductibles, A deductible is the amount you pay out of your pocket copays, and coinsurance) throughout the plan year. before your insurance pays. Once you meet the out-of-pocket amount, your The deductible runs from January –December each year. insurance provider will cover 100% of remaining Once you have met that dollar amount, you have met the medical expenses for the year. requirements for the plan year. What does a copay pay for? Copayments, or copays, are pre-set dollar amount you are expected to pay for office visits, procedures or prescription drugs under your insurance plan. Once the copay has been met, the insurance company pays all remaining costs. What does coinsurance mean? Coinsurance is a set percentage of service costs that you will be expected to pay once you have met your annual deductible. When your annual deductible is met, your insurance provider pays for their portion of the full cost of the service and you pay the coinsurance, or remaining percentage. What is an out-of-pocket maximum? An out-of-pocket maximum is the amount of money you may pay for medical services in the plan’s calendar year. Once you pay this amount, the plan will cover additional eligible expenses at 100%. 32 WestCare