Author Topic: coinsurance max vs max out of pocket  (Read 1883 times)

frugalnacho

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coinsurance max vs max out of pocket
« on: September 29, 2018, 11:55:45 PM »
I got a new job offer and I'm trying to evaluate the total compensation package.  I have several insurance plans to choose from, but they aren't making sense to me.  My understanding of how medical insurance (in the usa) works is like this:

I pay 100% of incurred medical expenses up to the deductible.  One that deductible is met insurance covers a portion and I cover a portion (in the example below it would be 80/20).  Once I meet the coinsurance maximum my insurance provider covers 100% of the cost. 

The first plan listed in the benefits package lists individual deductible of $1,500 and max coinsurance of $2,500.  But then it lists an out of pocket max of $6,350.  After I pay $1,500 for the deductible, and I incur another $12,500 in expenses (insurance covers $10,000 and I cover $2,500 which is 80/20 split) I reach the coinsurance maximum (after only paying $4k [$1.5k+$2.5k]).  So how is the total out of pocket max $6,350?  None of the 4 options add up correctly for the individual or family costs. 

What am I missing? 



Edit before I even posted: Is the discrepancy due to copays?  I didn't include it in the image, but the plan lists copays for various services and I'm assuming these copays do not count as coinsurance, but do count toward total out of pocket max, so I could incur an additional $2,350 of copays on top of my $1,500 deductible and $2,500 max coinsurance for this particular plan?

socaso

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Re: coinsurance max vs max out of pocket
« Reply #1 on: October 01, 2018, 04:11:52 PM »
That's a head scratcher but it seems like your idea about the copays might be right. It has been explained to me before that if you have coinsurance you still have to pay the copay and then the coinsurance kicks in. So if you have a $20 copay and 80% coinsurance then on a $100 visit you'd pay the $20 copay and $16 as your coinsurance (of the remaining $80). At least that was how that particular insurance explained it to me. I'd ask the insurance company, they might have their own fancy math.