Aik Designs

——- Creative Solutions ——-

Home » Medical Cost Sharing Plans: Important Definitions

Medical Cost Sharing Plans: Important Definitions

4 min read
Medical cost sharing plans

Health insurance policies provide a great way to buy affordable health coverage. These plans are available from many insurance companies, but they have to meet the standards for the charges that people enrolled in the plan pay when they use medical care. These plans are known as medical cost-sharing plans. In this post, we will see the top medical cost-sharing plans’ different types of cost-sharing charges.


What are cost-sharing charges?

It is the amount an individual pays for a medical service or item such as a physician visit, hospital stay, or prescription. The health insurance plan covers this amount. The cost-sharing charges of the top medical cost-sharing plans typically include a deductible, copayments, and coinsurance. However, not all healthcare-sharing plans may offer each type of cost-sharing.



It is the amount that a health insurance plan applicant should pay before the plan starts to pay for their medical services and items. Deductibles are set every year. So the enrollee must pay the full charge for most medical assistance until they have spent it. Once the amount is met, they will receive additional medical care during the same year and will not have to pay the full charge for those other services and items. The health insurance plan will pay a portion of these services, and the enrollee must pay the remaining cost based on coinsurance and copayments that apply to the service.

However, as per the regulations, the health insurance plans sold by the insurance companies have to pay the full charge for certain preventative care services that are delivered through the physician’s offices, pharmacies, hospitals, and other medical care providers, which are a part of the plan’s network. This means the enrollee should get these preventative services without paying a share of the cost, even if they have not met the deductible.



It is a fixed dollar amount that the applicant must pay towards the cost of a medical service or item they use and the insurance plan covers. These are common for prescription drugs and physician visits. The enrollee has to pay only a small amount for these healthcare services, and the plan will spend the rest.


This is the fixed percentage of the allowed amount for a covered service that the applicant should contribute. If the healthcare-sharing plan requires the enrollee to pay 20% of the allowed amount for lab tests, the remaining 80% will be paid by the insurance plan as per coinsurance.


In-network and out-network benefits

Most medical cost-sharing plans have a network of healthcare providers with whom they have negotiated the prices for certain services. These medical care facilities are called in-network. If an enrollee uses an in-network healthcare provider, some or all of the costs of the services delivered by the provider will be covered by the insurance plan, depending on whether the enrollee has met their deductible. It may also depend upon the type of services delivered.

However, some healthcare-sharing plans may also provide coverage for out-of-network services. But this may require the enrollee to pay a higher share of the costs for these services. The full charge of the service may also be higher since the out-of-network provider can charge more than the amount the plan has negotiated with in-network providers. 


What is the allowed amount?

Negotiated amounts with the in-network healthcare providers are called the allowed amount, negotiated rate, or eligible expense. The in-network providers agree to accept these payment amounts when an enrollee uses their services. The charges that the enrollee owes are based on the allowed amount. If the enrollee uses an out-of-network provider, the overall costs could be higher than the allowed amount, and they may have to pay excess due to a practice known as balance billing. No rules provide additional protection against certain kinds of medical bills.


Maximum limit on the total cost-sharing amount for out-of-network services?

There is a maximum out-of-pocket limit, also called the maximum annual limitation on cost sharing, which is the maximum an enrollee has to pay for all cost-sharing charges during a year. This applies to all marketplace health insurance plans. The law requires each insurance plan to have a maximum out-of-pocket amount that applies to all the covered essential health services delivered by the in-network providers. Insurance companies set out-of-pocket limits which are lower than the maximum amounts. The limits for a family plan are limited to twice as high as the maximum amount for an individual project.

The maximum out-of-pocket limit for a healthshare plan may change yearly as the amount will be adjusted to account for changes in the cost of private health insurance. This amount will be announced every new enrollment year in an annual notice.


Summing up

These are some of the basic and most important definitions of ‘cost-sharing charges that you should know before enrolling in a medical cost-sharing insurance policy.

5/5 (1 Review)

About Author