The coinsurance maximum is the maximum amount that an enrollee with individual coverage has to pay in coinsurance for covered medical expenses in a calendar year before benefits will be paid at 100 percent of the allowable charge. The coinsurance maximum provides participants protection against catastrophic health care expenses. The amounts paid toward meeting the calendar year medical deductible, preventive medications deductible, telehealth provider visit copayments, emergency room copayments and prescription drug copayments do not count toward satisfying the coinsurance maximum.
The initial $3,000 of coinsurance is applied to both the network and out-of-network coinsurance maximum. After the initial $3,000 has been met, only the coinsurance amount for services rendered by out-of-network providers will be applied to the additional $1,000 out-of-network coinsurance. Once the annual coinsurance maximum is met, the Plan pays 100 percent of the allowable charge for covered medical expenses for the remainder of that calendar year, except as otherwise specified.