The initial $1,000 of covered expense will apply to both the in and out-of-network family medical deductible. After the initial $1,000 has been applied, only services rendered by a non-participating provider will be applied to the additional $1,000 out-of-network family medical deductible.
Coinsurance Once a participant has met the calendar year medical deductible, the Plan pays a portion of the allowable charge for covered medical expense. The participant pays the remainder in the form of coinsurance.
Any fees charged by a non-participating provider that are above the allowable charge are not part of the coinsurance amount. The Plan will not pay any portion of these charges.
Helpful Tip: Participating providers agree not to charge any amount above the Plan’s allowable charge.
Individual Medical Coinsurance Maximum The medical coinsurance maximum is the maximum amount that each participant has to pay in coinsurance for covered medical expenses in a calendar year before benefits will be paid at 100%. The medical coinsurance maximum protects a participant from having to pay catastrophic medical bills in a given year. The amount paid toward meeting the calendar year individual and family medical deductibles does not count toward satisfying the medical coinsurance maximum.
The initial $2,000 of medical coinsurance is applied to both the in and out-of-network medical coinsurance maximum. After the initial $2,000 has been met, only the coinsurance amount for services rendered by non-participating providers will be applied to the additional $1,000 out-of- network coinsurance. Once the annual medical coinsurance maximum is met, the Plan covers 100% of the allowable charge for covered medical expenses for the remainder of that calendar year, except as otherwise specified. The Plan will never pay 100% for those expenses that do not apply toward satisfying the coinsurance maximum.
Do These Expenses Count Towards The Coinsurance Maximum?
The coinsurance paid for hospital inpatient services
The coinsurance paid for other covered medical expenses
The calendar year deductibles
The family deductibles
The prescription drug deductible
Expenses in excess of the allowable charge
Expenses in excess of Plan maximum limits
Coinsurance and other expenses for treatment of substance abuse (alcohol and/or drug) and mental health conditions