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Plan 70/30 offers $4000 Coinsurance Maximum. (outofpocket max N/A).

Plan 80/20 offers $4100 Out-of-pocket Maximum. (coinsurance max N/A)

Does that mean that if I get into an accident which requires $10000 in a year:

  • Under Plan 70/30 am I still on the hook for fees above $4000?
  • And under Plan 80/20 I am NOT liable for ANYTHING above $4100?
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    Are there also deductibles associated with the plans? – Hart CO Nov 18 '18 at 16:26
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This question is too broad as it's asked. Obviously, you should talk to you HR or the insurer, don't just assume things. But, as I don't think this person is coming back to give details but the system bumped this question to the top I'll go over the catching points for anyone else who may stumble here in the future.

It's very very very plausible that plan A has a deductible of $X and the $4,000 Coinsurance maximum accrues separately after the deductible is met.

This could occur under two scenarios:

  • There aren't many grandfathered plans out in the wild anymore but there are some and plan A might be one. If so throw away almost everything you read about "what's allowed" because there's a completely different rule book and deductibles and copays might not apply to "maximums."

  • If the plan is not grandfathered some carriers still present plans this way; with deductible and coinsurance indicated separately. The deductible plus the coinsurance maximum must still be below the maximum allowed out of pocket maximum allowed by the ACA, which for 2019 is $7,900.

With Plan B, there might be a deductible but it's explicitly indicating that your out of pocket maximum exposure is $4,100.

Without a pretty substantial amount of additional information it's not possible to say one way or another. So:

Under Plan 70/30 am I still on the hook for fees above $4000?

Maybe. If the plan is non-grandfathered, you could be on the hook up to $7,900 for 2019, if grandfathered, potentially higher.

And under Plan 80/20 I am NOT liable for ANYTHING above $4100?

Probably not. Though, ANYTHING refers to dollars spent on covered services. As an example, if your insurer approves 10 physical therapy visits but you go to 15 physical therapy visits, it doesn't matter that physical therapy is a covered benefit the additional 5 visits are not covered.

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There is not enough information to answer that for sure, you need to dig into the details of plan A to see what Coinsurance Maximum means exactly.

My assumption would be that - same as plan B - it means the max you would pay under any circumstances. otherwise it would be a meaningless number; however, that needs to be verified in the fine print.

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I don't understand that if they are telling you what the co-insurance maximum is then what is the out-of-pocket maximum? Or vice versa for the other plan? Be that as it may...

If the total approved medical cost was $10,000 and you have a 30% co-pay then you would be responsible for $3,000. If a 20% co-pay then you would be responsible for $2,000

If the $10,000 refers to charges not covered by the 70% or 80% then you would be liable for the respective maximums, namely $4,000 or $4,100.

You should verify this with the provider rather than taking the advice of anonymous strangers on the internet.

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