Individual coinsurance maximum
Our pre-health-reform plans refer to this as an out-of-pocket maximum that applies to your coinsurance. In general, it's the most you will pay in coinsurance for any one member of your plan during a plan year.
- "Coinsurance" is when you pay a percentage of the cost of a covered medical service or prescription directly to a provider.
- Your plan documents list what services you pay coinsurance for, and what percentage of those costs you pay.
- Once the coinsurance you've paid reaches your coinsurance maximum/out-of-pocket maximum, your plan begins to pay 100% for those services. See your plan documents to learn if there are exceptions.
Some plans have two different coinsurance maximums
- Coinsurance you pay to providers in your plan's network applies to your "in-network" or "preferred" coinsurance maximum.
- Coinsurance you pay to providers outside your plan's network applies to your "out-of-network" or "alternate" coinsurance maximum.
Costs that don't count towards your coinsurance maximum
- Any costs that apply to your deductible
- Copayments (fixed dollar amounts) for doctor visits and other services
- Costs for services your plan doesn't cover
Other costs may be excluded by your plan; see your plan documents for details.