Best Answer: When you get health insurance, there is what is called a premium. This is the amount you pay on a scheduled basis. For instance, if you get insurance through your employer, you would pay your part of the premium each payday.
If you pay your premiums on time, you get to keep your insurance. Now, when you use your insurance, there is what is called a deductible. This is an amount of money you must spend before the insurance starts paying anything. A typical deductible might be $250/year for the policy holder and $500/year for the family. So, if your dad had the policy and went to get a prescription, if it was his first prescription of the year and it cost $100, he would pay $100. Every time he used stuff under the plan, he would pay everything until he hit the $250 deductible, then the insurance would kick in. (the same goes for the family coverage, until the $500 was met by everybody in total - not separately - you would pay 100%).
Now, once the deductible is met, the insurance starts picking up some of the costs. usually the costs are based on what doctor or provider you use. If you use someone who is called "in network" the insurance company pays more of the bill. They do this because they have negotiated lower costs with that provider. For example, let's say you need to have some tests done
and your family has met all your deductibles. Let's also say the tests normally cost $200. If you go to an in network provider, the insurance would cover 80%. If you go out of network, the insurance might only cover 70%. Now the nice thing is, by going in network, you get the discounted price, let's say $160. So, if you go in network, you would pay $32 for the tests and the insurance would pay $128 (totaling $160). If you went out of network, you would pay the 30% of $200 or $60 and the insurance company would pay $140. So, by staying in-network, both you and your insurance company save money.
Also, there is something called an out-of-pocket maximum. This just means that if someone in your family gets real sick or injured, the most you can pay for that year is the out-of-pocket max. say $5,000. Once you hit that, everything after that is covered 100% by your insurance and you don't pay anything.
Last, there is a co-pay - what this means is that if you go to the doctor for a routine visit, it is usually covered without worrying about the deductible and you pay just the co-pay. usually this is $15 or $20 on say a $100 office visit and the insurance company pays the rest (based on a negotiated amount).
And that's the short version of how insurance works.
Steve D · 7 years ago