Health Insurance Deductibles, Coinsurance and Maximum Limits
Once you understand the different parts of your health insurance costs, you’ll want to know how these work together and what your out-of-pocket costs may be. Below are a few examples of how deductibles, coinsurance and maximum limits work together.
Example #1: Deductibles, Coinsurance and Out-of-pocket maximum
Your health plan has a:
- $4,000 deductible
- 25% coinsurance
- Out-of-pocket maximum of $5,000
- You must pay $4,000 toward your medical costs before your plan begins to cover costs.
- After you pay the $4,000 deductible, your plan covers 75% of the costs, and you pay the other 25%.
- When you've paid $5,000 out of your pocket toward your medical costs, your plan covers 100% of your costs until your "plan year" renews. A plan is good for 1 year.
When the next plan year begins, your deductible and coinsurance reset. You are once again responsible for the $4,000 deductible and 25% coinsurance.
Example #2: Coinsurance After You've Met Your Deductible
Let's say you fracture your hand while playing sports and you need an X-ray. If you've already met your annual $4,000 deductible, your coinsurance goes into effect. In this example, that means that your plan now pays for 75% of your benefits while you pay the other 25%.
Here's a break down of those costs:
- The X-ray for your hand costs $200.
- Your plan covers 75%, which is $150.
- The amount you pay out-of-pocket cost, or your coinsurance, is $50.
Example #3: Maximum Limits
Your health plan sets a maximum limit for certain tests, procedures and medical services. This means that it will cover up to a certain amount for these services. These limits help lower costs for all members by keeping rates fair and reasonable.
Let's say your doctor charges more for the above hand X-ray.
- Your health plan covers a maximum of $200 for an X-ray.
- Your doctor charges $250.
- You may have to pay the $50 difference.