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Deductibles, Coinsurance and Maximum Limits

When buying health insurance, you need to know how your health plan works and what your out-of-pocket costs may be. We'll look at a few examples of how deductibles, coinsurance and maximum limits work. You may want to read Health Insurance Costs so you know all the terms used below.

Example #1: Deductibles, Coinsurance and Out-of-Pocket Maximum

You have an insurance plan that has a:

  • $5,000 deductible
  • 20% coinsurance
  • Out-of-pocket maximum of $6,000

This means:

  • You must pay the first $5,000 of your medical costs.
  • After that, your plan covers 80% of the costs, and you pay the other 20%.
  • When the amount of coinsurance you've paid reaches $6,000, the plan covers 100% until your "plan year" renews. A plan is good for 1 year.

At the start of each year, your deductible and coinsurance resets for the next plan year and the $5,000 deductible and 20% coinsurance will start again.

Example #2: Coinsurance After You've Met Your Deductible

You bruise your hip in a fall and you need an X-ray. You've met your annual $5,000 deductible so your plan now pays for benefits. What you pay to see your doctor depends on your coinsurance, which in our example, is 20%.

Here's how the costs might break down:

  • The X-ray costs $200.
  • Your plan covers 80%, which is $160.
  • Your out-of-pocket cost, or coinsurance, is $40.

Example #3: Maximum Limits

Your plan covers up to a certain amount for tests, procedures and medical services. These limits help keep rates fair and reasonable, which helps lower costs for all members.

Let's say your doctor charges more for an X-ray.

  • Your plan covers a maximum of $200 for an X-ray.
  • Your doctor charges $300.
  • You may have to pay the $100 difference.