Deductible, out-of-pocket — where does it end?

I recently had a day surgery, and am now getting all of the bills.  I thought that I would be paying the $1,000 deductible and I’d be done.  I’m trying to understand the letters from the plan, which show that I should be paying more than $1,000 with my “out-of-pocket”.  What is the difference between the deductible and the out-of-pocket?  I don’t earn a lot of money and I need to know how much I’m going to have to pay.


Dear Confused,

The deductible is how much you will pay before the plan starts helping you pay your medical bills. After you reach the deductible, most plans will pay a percentage of your bill and you pay the rest. This is called “co-insurance”. For example, a plan might pay 80 percent and you will pay 20 percent after the deductible is spent.  Your out-of-pocket will include the deductible and the coinsurance — your 20 percent share.

Plans set a maximum out-of-pocket amount, after which the plan pays for all of your covered medical bills.  Call the member services number on the back of your card or ask your employer what your plan’s maximum out-of-pocket is.

The Affordable Care Act sets limits on deductibles and coinsurance, based upon your family income. You may qualify for help paying these in 2014. When your plan has its annual sign-up, ask for information about this.

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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.