This is how coinsurance works with most other health insurance plans. For most individual health insurance plans, you are responsible for meeting a deductible before your health insurance will pay for your healthcare cost. Once your deductible is met, then you pay you are responsible for your coinsurance or percentage of the remaining costs until you reach your out of pocket maximum.
For example, if somebody has 60/40 coinsurance, this means once they have met their deductible, the insurance company will then pay 60% of the remaining cost and you will pay 40% of the remaining cost until you reach your out of pocket maximum. Once you reach your out of pocket max, then you should be covered 100% for the rest of your calendar year for covered services. Let’s give another example.
Health Insurance Plan
$8,00 out of pocket max
Let’s say I fell and broke my arm which actually did happen and I needed to have surgery. The total bill comes to $20,000 and now I would be responsible for the $5000 because that is my deductible. That leaves a remainder of $15,000. From there, I will now pay my coinsurance or percentage of that remaining balance. In this case, I will be responsible for the remaining 20% and my insurance will help me pay 80%. So if I take the remaining bill of $15,000 and multiply that by 20%, that total comes to $3,000. So if I add up my deductible of $5,000 and the coinsurance I paid of $3,000, that comes to a total of $8000 which is my out of pocket max. This means that my insurance will take care of the rest of the bill. so for that $20,000 bill, my insurance will pay $12,000.
To sum it all up, you first pay your deductible, then pay your coinsurance , until you reach your out of pocket maximum, at which then you will then be 100% covered for the remainder for the year for the covered services.