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Our company switched health care providers and I'm a little confused because the provider doesn't call out "coinsurance". So for example, on this base plan, if I were to meet the $3000 family deductible, there is no indication as to who will pay what percentage of the next bill (up to the OOP Maximum of $10,000).

So, who will pay the $7000 difference between the $3000 deductible and the $10,000 OOPMax? Surely I will pay it, but at what rate? I asked my HR manager and I think I just confused her.

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  • It appears that there are a number of different copays for a number of different items. If the next bill is a visit to urgent care, you'd have a $100 copay. If the next bill is for complex imaging, you'd have a 20% copay. Nov 30, 2020 at 22:25
  • @JustinCave Okay thanks, so to me, that sounds like "I get hurt, go to urgent care, bill is $3000, I pay that". Then, again, "I get hurt, go to urgent care, bill is $3000, I only pay $100 because I met deductible".
    – Tyler M
    Nov 30, 2020 at 22:36
  • No, if you go to urgent care, you pay $100. However, your treatment may involve, for example, being referred to outpatient hospital care, for which you will pay out-of-pocket until you meet your deductible, after which you will pay 20% of the remaining bills until you mean the OOPM.
    – chepner
    Nov 30, 2020 at 23:06

2 Answers 2

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Other plans may be different, so I'd confirm with your benefits department (maybe dealing with one issue at a time as to not overwhelm them), but you would pay the difference between the deductible and the max-out-of-pocket. That $7,000 can be a mixture of co-pays and "after-deductible" charges (e.g. 20% of complex imaging costs). Here's a few basic things that may help (again, confirm with your HR):

  • Co-pays do NOT count toward your deductible, but DO count toward out-of-pocket
  • After your deductible is met, 80% of any hospital care ("Inpatient & outpatient...") and imaging is paid by insurance, meaning that 20% is paid by YOU. That also counts toward your max out-of-pocket.

So depending on what services you use and what gets charged, you may pay toward that $7,000 even before you reach your deductible.

I'm not judging whether this is a good plan or not. It depends on what the premium is, how much you expect to use, and what alternatives there are. It also may make a difference if you want to qualify for a High-Deductible Health Plan (HDHP) in order to have a Health Savings Account (HSA). But that may help you determine where your medical charges will come from.

If you want a "bottom line" to judge the plan, the MOST you'll ever pay in a year is $10,000 for the family (plus the premiums, of course). If you don't have any major medical bills, then you're just paying copays as needed. If you have a few significant injuries, you'll pay somewhere in between (paying the deductible first, then 20% after that).

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  • Thanks for your response. Do you see anywhere in the outlined summary, anything that would look like an Urgent Care Clinic? Unless I'm mistaken, that wouldn't fall under the "Inpatient & Outpatient Hospital Care, Facility & Physician Services" so I understand I would pay a $100 copay, but if my visit did cost an additional, say, $1000 after i've already met my deductible, do I still only pay the $100 copay? I.e. my Urgent Care coinsurance is basically 0% (+$100) after deductible?
    – Tyler M
    Nov 30, 2020 at 22:43
  • copay and coinsurance are different. If you want to urgent care, it would cost $100 even before you've met your deductible. If they sent you to the hospital, those charges would count toward your deductible (and you'd pay 20% coinsurance after that).
    – D Stanley
    Nov 30, 2020 at 22:53
  • @TylerM - Yes. But your second urgent care visit could certainly involve a bill (or several) for "Outpatient Physician Services" which you would pay 20% of and/or a prescription for one or more drugs that would incur additional copays. Nov 30, 2020 at 22:54
  • So basically only hospital services and "complex imaging" count toward your deductible from what I can see. The rest is covered by copays (that do NOT count toward the deductible).
    – D Stanley
    Nov 30, 2020 at 22:54
  • So depending on what services you use and what gets charged, you may pay toward that $7,000 even before you reach your deductible. Not sure that I follow this. How could one satisfy the $7k out-of-pocket before the deductible? It has been a while but when I had such plans, all fees came out of my pocket until I met the deductible at which time the copays kicked in at the scheduled rate until the maximum out of pocket was reached. Nov 30, 2020 at 22:58
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Looking at the table you posted in your question, it is missing to coinsurance information. In my experience they usually include a line about the coinsurance percentage even it appears that almost any covered item would fall under labs, in-patient, out-patient, Rx...

In your case the only hint at Coinsurance is in the 20% you are responsible for in the complex imaging, and inpatient & out-patient hospital care, Facility and physician services.

One place to look is the part of the document where they include a few examples. In my company they detailed what it would cost if a person was pregnant, or had diabetes, or broke a bone. See if there is any mention of coinsurance.

While the table you included is labeled the base plan, it doesn't detail the difference between in-network, and out-of-network. In my companies plan the word coinsurance only appears twice in the in-network column, but it appears more than a dozen times in the out-of-network column.

If you didn't get an answer that helps from your HR person, you can call the insurance company. It won't be quick, but they should be able to explain it.

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