Preventive Services
All marketplace plans cover preventive services for free. This means that things like annual physicals, vaccinations, and routine bloodwork are covered at no cost to you. No copay, no deductible.

Copays
Copays are fixed amounts you pay for specific services. For example:
- Primary Care Visit: $35 per visit
- Specialist Visit: $55 per visit
- Urgent Care: $35 per visit
- Generic Drugs: $3 per prescription

These amounts are set and do not count toward your deductible.

Deductibles
The deductible is the amount you pay out of pocket for certain services before your insurance begins to share costs. For example, major expenses like surgeries, emergency room visits, X-rays, and MRIs typically go toward your deductible.

Coinsurance
Once you've met your deductible, coinsurance kicks in. This is a percentage of the cost that you share with your insurance company. For example:
- 65/35 Coinsurance: The insurance covers 65% of the cost, and you pay 35%.
- 50/50 Coinsurance: Costs are split evenly between you and the insurer.

Out-of-Pocket Maximum
This is the maximum amount you'll pay in a year for covered services. Once you hit this limit, your insurance covers 100% of covered expenses for the rest of the year.

Example Plan: Everyday Gold (Ambetter)
- Monthly Premium: $58.95 (with tax credit)
- Deductible: $750
- Out-of-Pocket Maximum: $7,000
- Coinsurance: 65/35

Scenario: You need to visit the emergency room, and the total cost is $10,000.
1. You pay the first $750 to meet your deductible.
2. After that, coinsurance applies. You pay 35% of the remaining $9,250 ($3,237.50), while insurance covers 65%.
3. Once your total payments reach $7,000 (your out-of-pocket maximum), insurance pays 100% of covered costs for the rest of the year.

Key Takeaways
- Preventive services are free.
- Copays are set amounts for basic services and do not count toward your deductible.
- Major expenses go toward your deductible before coinsurance kicks in.
- Once you hit your out-of-pocket maximum, you're fully covered for the year.

Contact Ashley Insurance for help today.