Deductible + Coinsurance = Out of Pocket Maximum

Deductible + Coinsurance is Equal to and Not Greater than the Maximum Out of Pocket

Copays

A "co-payment" or "co-pay" is a specific charge that your health insurance plan may require that you pay for a specific medical service or supply.

 

For example, your health insurance plan may require a $25 co-payment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges. Copay's are also common for; Emergency room, X-rays, Pap, Testing etc.....


Note: Be sure to check your plan summary, plans differ greatly on copay's!

Deductible

The portion of any claim that is not covered by the insurance provider. It is normally quoted as a fixed amount 
and is a part of most policies covering losses to the policy holder. The deductible must be "met", that is, paid by the insured, before the benefits of the policy can apply. Dr. office visits "co pay's" are generally NOT subject to deductibles for sickness related visits.  But there are several exceptions. 

 

It is very important to discuss each different Insurance carriers plan benefits in detail.  Some companies charge deductible and coinsurance for specialists visits as a result of an accident but not for sickness visits.

Co-Insurance

Expressed as a percentage or pair of percentages generally with the insurer's portion stated first. 


Most Insurance companies policies offered at Healthy Florida are 20% Customer, 80% Insurance company. 80/20.

 

Coinsurance indicates how an insurer and an insured will share the costs of a bill that exceeds the insurance policy's deductible up to the policy's stop loss. Once the insured's out-of-pocket expenses equal the stop loss the insurer will assume responsibility for 100% of any additional costs.

Note: As of 2010 United Healthcare is offering  0%, 20% and 30% coinsurance.  Ask your Healthy Florida representative to explain how these can benefit you.

Out-of-Pocket Maximum

Maximum amount you will payout of your own pocket for covered medical expenses.


In a given "Calendar Year" (January1 -December31).  

Plans may vary on weather Deductible and Coinsurance is part of the total, which it generally is.


Some people have called "Out of Pocket Maximum | Maximum out of Pocket" by the phrase the "Bottom Line", "Worst Scenario". The Health Insurance Industry does not use these phrase technically.

 

Note: Plan Summaries will state "Out of Pocket Maximum" or "Maximum out of Pocket" 

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