What happens after I pay the deductible? What is “coinsurance”?

My eight-year-old son took up ice hockey.  At his third game, he got hit in the head and ended up in the emergency room.  He had some x-rays and got checked out.  My health plan from work has a $1,000 deductible.  But the hospital says I owe $1,122, after the plan has paid.  I thought we were done after the $1,000.  Why do I owe more than $1,000?  I’m a lot less excited about ice hockey these days, but we have already bought all of the (expensive) equipment.  If I have to pay a lot more than the deductible for my son’s medical bills, I may have to ice his hockey dreams.

Tapped Out Dad

Dear Tapped Out Dad,

You have entered the Coinsurance Zone.  Think of your health insurance as layers.  In the deductible layer, you are paying the bill.  That is your $1,000.  In the next layer, you pay part of the bill and your plan pays part.  This is called “coinsurance”.  Different plans pay different percentages in this layer: it could range from 60% to 80%.  If your plan pays 80 percent, then you pay 20 percent.  The $122 is your 20 percent share of the hospital bill. 

The coinsurance layer ends at a certain point and then the plan pays all of the bills.  (Or at least, all of the bills for services that are covered.)  This is called the maximum out of pocket.   Find out your plan’s maximum out of pocket, before you hang up your son’s skates. 

 

Deductible                         

  • You pay 100% up to $1,000 (example)

Coinsurance                       

  • Plan pays 80%  and you pay 20% up to $500 (example)

Maximum out of pocket        

  • The total dollars that you will pay before the plan pays 100%         
  • Deductible + coinsurance = $1,500 (example)

After maximum out of pocket                                                          

  • Plan pays 100% of covered services
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Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.