The individual 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 percent. 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 $3,000 of medical coinsurance is applied to both the network and out-of-network medical coinsurance maximums. 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 medical coinsurance maximum is met, the Plan covers 100 percent of the allowable charge for covered medical expenses for the remainder of that calendar year, unless otherwise specified.
Do these expenses count toward the Coinsurance Maximum?
Expense Type | Counts Towards Coinsurance Maximum |
|---|---|
Coinsurance for hospital inpatient services | Yes |
Coinsurance for other covered medical expenses | Yes |
Calendar year deductibles | No |
Family deductibles | No |
Prescription drug deductible | No |
Primary care office visit copayments | No |
Telehealth provider visit copayments | No |
Emergency room copayments | No |
Prescription drug copayments | No |
Generic drug differential amounts | No |
Utilization review penalties | No |
Expenses in excess of the allowable charge | No |
Expenses in excess of Plan maximum limits | No |
Services not covered by the Plan | No |
Services not considered medically necessary | No |