Health Insurance Factors

A number of factors play a part in your health insurance coverage. Before out-of-pocket maximums come into play, you must satisfy any deductible and coinsurance obligations.

Deductibles

Your health insurance deductible is the amount for which you are fully responsible during the year. If your plan’s deductible is $1,000, then you must pay the first $1,000 of your health care before you become eligible for insurance benefits.

Coinsurance

Most health care plans have coinsurance percentages. The coinsurance is the amount you share with the insurance company after the deductible is met. For example, if your coinsurance is 80/20 and you receive a health care bill for $100, the insurance company will pay $80 (assuming you’ve met your deductible), and you are responsible for paying the remaining $20.

Out of Pocket Maximums

You must pay coinsurance amounts until your reach your out-of-pocket maximum. Once you reach it, the health insurance company will pay your covered health care costs in full for the balance of the year. If your out-of-pocket maximum is $2,500, you are not obligated to pay more than that amount.

Premiums

Your monthly premiums never factor into your deductible or your out-of-pocket maximum. You can lower your premium rates by increasing your deductible, coinsurance and / or out-of-pocket maximum amounts.