Health insurance can seem a bit overwhelming, so we thought a few terms defined might be helpful as you consider your current policy or look to purchase a new one!

Coinsurance is the percentage of covered medical expenses that you pay after you’ve met your deductible. Coinsurance is usually listed as a percentage. For example, if your plan lists coinsurance at 20% of covered medical expenses after you’ve met your deductible, then the plan pays 80% of covered services, and you pay 20% until you reach your coinsurance maximum.Coinsurance maximum The coinsurance maximum is the total amount of coinsurance that you’re required to pay for covered medical services in a plan year. Once you reach the coinsurance maximum, your plan usually covers 100% of all covered services for the remainder of the benefit period. Under a traditional health plan, you would continue to pay any copayments for covered services, such as office visits or prescription drugs. Under a high-deductible health plan, your covered medical services would be paid 100%.

Out-of-pocket maximum

Your out-of-pocket maximum is the maximum amount you would be required to pay in a plan year for covered medical expenses. With a high-deductible health plan, this amount is usually the total of your deductible plus your coinsurance maximum. Knowing the definitions of some common terms associated with health insurance may help you make better decisions about choosing a plan that’s right for you.

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Many BCBSNC applicants ask the question…. What is coinsurance?  BCBSNC defines coinsurance as “the percentage of the allowed amounts for covered services that BCBSNC will pay after you meet your deductible.”  In other words, it is the percent that the insurance company is responsible for paying towards your medical bills.  When does coinsurance come into play?  When you have to go into the hospital, have diagnostic testing such as MRIs, CAT Scans, or x-rays, or if you have surgery in a free standing surgery center. 

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

How do health insurance deductibles and out-of-pocket amounts work?

A deductible is the amount you must pay before the insurance company begins to pay any policy benefits. This is usually an annual amount per insured person, per calendar year.  Although typically there will be a maximum amount of deductibles you will have to pay per family in any given year.  For example, if your “per person” deductible is $500, and you have five people in your family covered under your health insurance, the maximum “family” deductible is usually three times the individual deductible or $1500.00 in this example.  Once three individuals have paid the $500 deductible, no more deductibles will apply to any member of the family for the remainder of the year.  (more…)