De-mystifying Health Insurance
February 6, 2025
Premium- this is the amount you pay per month for health insurance, whether you have met your deductible and out-of-pocket maximum or not. If using the marketplace, make sure to estimate your traceable income accurately because people get sizable subsidies.
Deductible- this is the amount that you pay before your insurance “kicks in”. Sometimes, services like your wellness checkup with a primary care doctor or psychotherapy are covered even before you meet your deductible, it’s plan-dependent. These days, it’s better to assume nothing is covered and to ask for an estimate directly from the insurance company before you get a service or prescription. For therapy, you want to ask about: “cost for office visit with an in network provider for CPT code 9087”
Co-pay - this is a flat fee you pay for either services like primary care visits or prescriptions (e.g., some plans will say “$40 CO-PAY) that means you will pay a flat fee of $40. Note: this is AFTER you have met your deductible. Before you have met your deductible you will be responsible for the full fee for both services and prescriptions, unless your plan allows for the exceptions to the deductible stated above (often wellness checkups are covered).
Co-insurance - this is a percentage of the service fee or prescription for which you are responsible. Note: this is AFTER you have met your deductible. Before you have met your deductible you will be responsible for the full fee for both services and prescriptions.
Important note: Co-pays and co-insurance apply to urgent care, specialist visits (e.g., you see an orthopedist or a neurologist in a specialty clinic), and emergency room visits. If you want to make sure you have a catastrophic plan that does not put you in ten grand of debt if you get hit by a car, scroll to the emergency and urgent care coverage and see what the co-pay or co-insurance is. It is almost always different than for all other services because this is where insurance companies like to pay the least.
A note on prescriptions
If you have prescriptions you take regularly,check if they are name brand or generic. This makes a huge difference in how much you will pay. A good example of a name brand drug is Vyvanse the ADHD drug, which didn’t have a generic version until very recently.
Some drug coverage policies exclude “non-preferred” drugs from coverage entirely. To check this, scroll the “prescription drug coverage” section of your healthcare plan. If you are a person who takes a name brand drug, you can look it up in your insurance company’s drug coverage guide for 2025. Yes, it’s dry and awful to dig through but yes, it could be the difference between a plan where your life-saving drug is covered and one where you find out that without insurance it costs $10,000.
Charity Care
If you go to Duke or UNC for healthcare, look into “financial assistance”. Both systems have a “charity care” program that’s funded through donations or endowment that covers fees for those unable to pay, but you have to submit paperwork showing your limited income BEFORE something goes down that takes you for hundreds of dollars.
"Therapy isn't curing somebody of something; it is a means of helping a person explore himself, his life, his consciousness." - Rollo May