Out-of-pocket max’s are determined by coverage level (single vs plan with dependents) and salary. Your out-of-pocket max is the summation of everything you have paid for your medical services received this includes deductible, coinsurance and copay. In network and out-of-network services are subject to separate out-of-pocket maximums. Once you meet your out-of-pocket maximum, the Plan pays 100% of covered services you receive. Out-of-Pocket Max – the maximum amount you pay each calendar year to receive covered services after you meet your deductible. If you seek a Tier 1 provider for physical therapy, then your copay will be $35. If you are on the PPO plan and you see a Tier 1 provider for a standard sick visit, then your copay at the time of the visit will be $20. The health plan comparison chart is the best resource to understand what your copay is for a covered service within any of the tiers. Your copay does not count towards your deductible.Ĭopay amounts vary based on the plan design. Only the PPO Plan offers a copay option for specific covered services. The 10% you pay will count towards your deductible.Ĭopay – a fixed dollar amount you must pay to a provider at the time services are received. If you are on either plan and have hit your Tier 1 deductible and visit a Tier 1 urgent care provider, the plan covers that service at “90% coinsurance after deductible.” This means you will pay 10% of the cost of the visit and your insurance will cover the remaining 90%.
Most Tier 1 services are covered at “90% coinsurance after deductible,” while Tier 2 services are “75% after deductible and Tier 3 are “60% after deductible.”
HSA-Eligible and PPO Plansįor services covered by “coinsurance after deductible” the amount you pay in co-insurance continues to count towards meeting your next Tier deductible. If you have met this, you would pay an additional $100 towards your services and then would have met the Tier 2 deductible of $2,500.Ĭoinsurance – the percentage of cost of a covered health care service you pay once you have met your deductible. With a $1500 Tier 1 deductible on the HSA-Eligible Plan with single coverage, you pay the first $1500 of covered services yourself. The health plan comparison chart shows deductible amounts for Tier 1, Tier 2 and Tier 3, but you should think of your deductible as one sum of the money you have paid for your services. Some covered services require you to meet the deductible first, while other covered services are paid with a copay. HSA-Eligible PlanĪll covered services require you to meet your deductible first and then services will be covered through coinsurance. These hard to understand health care vocabulary terms are explained below to help make understanding your health care plan much simpler!ĭeductible – the amount of out-of-pocket expenses you pay for covered health care services before the insurance plan begins to pay. It is important to understand how your health care plan operates, but far too often the tricky benefit jargon of “deductible, coinsurance, copay, and out-of-pocket max” get in the way.
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