Medical
- This section is broken down by medical benefit, tiers (aka how it is covered, e.g., Coordinated), and limitations (aka how this benefit is governed).
Insurance Basics
Deductible
- Definition: The amount you must pay out-of-pocket for covered services before your health insurance starts to pay.
- Example: If your deductible is $1,000, you’ll need to pay the first $1,000 of your medical expenses each year before your insurer beings to pay its share of covered services.
- Understanding embedded vs. aggregate deductible
Out-of-Pocket Maximum
- Definition: The most you will have to pay in a policy period for covered services. The out-of-pocket maximum includes deductibles, copayments, and coinsurance, but not premiums.
- Example: If your out-of-pocket maximum is $2,000, once your out-of-pocket expenses reach $2,000, your insurance will begin to cover 100% of your remaining covered healthcare costs for the rest of the policy period.
Copay
- Definition: A fixed amount you pay for a covered healthcare service, usually at the time of service.
- Example: You may pay a $20 copay for a doctor’s visit. This $20 will not count toward your deductible, but it may count toward your out-of-pocket maximum.
Coinsurance
- Definition: The percentage of the cost of a covered service that you are required to pay after reaching your deductible.
- Example: If you have a $200 medical bill for a service and the coinsurance is 20%, you would pay $40 and your insurer would cover the remaining $160.
Limitation
- Definition: A restriction on your coverage, such as a set number of visits allowed for a specific service.
- Example: If your chiropractic visit limitation is set to 20 visits per plan period, your 21st visit will not be covered by your insurance.
Excluded Services
- Definition: Certain healthcare services that are not covered by your health insurance plan.
- Example: If you are seeking a $400 medical service that is not covered by your plan, you will need to pay the full $400 out-of-pocket. This $400 will not apply to your deductible or to your out-of-pocket maximum.