• A deductible is the amount you pay for health care services before your health insurance begins to pay.
Let's say your plan's deductible is $2,600. That means for most services, you'll pay 100 percent of your medical and pharmacy bills until the amount you pay reaches $2,600. After that, you share the cost with your plan by paying coinsurance and copays.
Our plan has Routine, Preventive and Wellness Services that are not subject to the deductible and are covered at 100%.
• Coinsurance is your share of the costs of a health care service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you've paid your plan's deductible.
Here's how it works. Joan has allergies, so she sees a doctor regularly. She just paid her $2,600 deductible. Now her plan will cover 70 percent of the cost of her allergy shots. Joan pays the other 30 percent; that's her coinsurance. If her treatment costs $150, her plan will pay $105 and she'll pay $45.
If Joan has a PPO plan, she has the option to see any doctor she wants. If she goes to an out-of-network doctor, her plan will still share the cost, but her percentage of coinsurance will be higher. And, if the medical service she gets is more than what her plan would pay for an in-network doctor, she'll have to pay the difference.
Our plan has no co-insurance for covered, in-network services once the deductible is met. The out of network deductibles are higher and there is an out of pocket maximum. What you pay goes toward your deductible first. Once you’ve met that amount for the year, further out of network payments accumulate on top of that deductible amount until you meet your out-of-pocket max. The amount you pay for covered services with an out of network provider is 40%. That 40% is your coinsurance.
• A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.
For example, a doctor’s office visit might have a copay of $30. The copay for an emergency room visit will usually cost more, such as $250. For some services, you may have both a copay and coinsurance.
Our plan does not have a copay.
Out of Pocket Maximum
• The most you will have to pay for covered medical expenses in a plan year through deductible and coinsurance before your insurance plan begins to pay 100 percent of covered medical expenses.
Your deductible is $3,000 for out of network services. You will pay that first $3,000 of your bill as your deductible. Then, your coinsurance kicks in. Insurance company pays 60% of your covered medical expenses. You'll be responsible for 40% of those expenses—until the remaining $2,000 of your $5,000 out-of-pocket maximum is met. Then, our plan covers 100% of your remaining qualified medical expenses for that calendar year.
The out of pocket maximum for in-network services matches our in network deductibles.