What do we call percentage of costs of a covered service the patient pays after they have met their deductible?

How Deductibles & Co-Insurance Work

Deductibles, coinsurance, copays and out-of-pocket maximums are the basic elements to any health care plan.  In short: you will first pay your deductible, then you will pay the percentage of coinsurance on your policy up to the out-of-pocket maximum, and then the plan will pay the rest of your costs for the remainder of the year.

Deductibles

A deductible is the amount that you
pay for medical services before the plan begins to contribute toward expenses.  In all of IU’s medical plans, you will pay 100% of the costs (at the “discounted” contracted rate) for medical services until you reach the deductible (except for in-network preventive medical services which are covered by the plan at 100%). 

For the HDHP plans, all covered services, including prescriptions, are subject to the deductible except for wellness/preventive medical
services and preventive prescriptions. For the $500 Deductible plan, the deductible applies to all covered services except emergency room and in-network urgent care center copays, preventive medical services, prescription drugs (except drugs administered in a Physician’s office), and transplants.

2022 in-network deductibles

IU Health HDHP:

  • $2,700 employee only coverage
  • $5,400 all other coverage levels

Anthem
PPO HDHP:

  • $1,700 for employee only coverage
  • $3,400 all other coverage levels
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Anthem PPO $500:

  • $500 per individual
  • $1,500 family maximum

If you have employee only medical coverage, then once you have enough expenses to meet the deductible, you move into the coinsurance phase of your coverage.

If you have employee and spouse, employee and child(ren) or family coverage level then the family
deductible is structured differently based on the type of medical plan you are enrolled in – HDHP or Traditional Deductible plan.

High Deductible Health plans
(Anthem PPO HDHP and IU Health HDHP):

  • With Family coverage, when one or more family members are covered, the entire family deductible must be met before services are covered for any member – there is no individual deductible for those enrolled in employee/spouse, employee/child(ren), or family
    coverage.  The family deductible can be satisfied by the costs incurred by one or more family members.

Traditional Deductible plans
(Anthem PPO $500):

  • With Family coverage, each covered person in a family has a separate, individual deductible (the employee only deductible level listed above) that they must meet during the year before the plan begins to share in the cost of services for that individual. Once each individual has incurred enough
    expenses to meet the individual deductible then they move to the coinsurance phase.  However, when there are 3 or more covered family members, the deductible is considered met when the combined individual deductible expenses reach the ‘family’ maximum amount.  Each enrollee may contribute no more than the amount of the individual deductible to the family maximum.

Co-Insurance

In addition to a deductible, health insurance also has coinsurance. Co-Insurance is
the percentage of the costs that you share with the plan once you have met your deductible.  Each of IU’s medical plans has your share of the coinsurance set at 20%.  That means you will pay 20 percent and the plan will pay 80 percent of the costs for in-network services once the deductible has been met.

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There is a completely separate deductible and coinsurance rate for the Anthem plans when out-of-network providers are used.  The IU Health HDHP does not offer out-of-network
benefits.

Out-of-Pocket Maximums

The Out-of-Pocket Maximum protects you from high medical bills. When the deductible amounts and coinsurance amounts equal the plan’s Out-of-Pocket Maximum then the plan pays 100% of covered charges for the remainder of the plan year.

2022 out-of-pocket maximums

IU Health HDHP:

  • $3,400 employee only coverage
  • $6,800 all other coverage levels

Anthem PPO
HDHP:

  • $3,400 for employee only coverage
  • $6,800 all other coverage levels

Anthem PPO $500:

  • $2,400 per individual
  • $7,200 family maximum

Special Notes regarding Prescriptions:

For all Medical plans, there are some prescriptions as part of the Affordable Care Act (ACA) that are covered by the plan at 100%. 

In addition, for the HDHP plans, there are other preventive
medications that are allowed to bypass the deductible and are subject only to coinsurance. So for those preventive prescriptions, you only pay 20% of the cost for the medication. Download a list of examples of preventive medications or contact CVS Caremark directly at www.caremark.com or
1-866-234-6952.

The traditional medical plans (the $500 Deductible plan) have set copays for prescriptions.  The copays for prescriptions are not applied toward the medical plan’s deductible, coinsurance, or out-of-pocket maximum. Retail and mail order prescription copays are based on a tiered drug list. In general, Tier 1 is generic drugs, Tier 2 is preferred brand drugs, and Tier 3 includes non-preferred drugs. There is a separate
out-of-pocket maximum from the medical plan on in-network prescription copays.

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Which is the percentage the patient pays for covered services after the deductible has been met?

Coinsurance is a portion of the medical cost you pay after your deductible has been met. Coinsurance is a way of saying that you and your insurance carrier each pay a share of eligible costs that add up to 100 percent.

What is the name for the percentage of the cost that the patient must pay?

The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.

What is deductible and coinsurance?

A deductible is the amount you pay for health care services before your health insurance begins to pay. How it works: If your plan’s deductible is $1,500, you’ll pay 100 percent of eligible health care expenses until the bills total $1,500. After that, you share the cost with your plan by paying coinsurance.

What are deductibles and copays?

Copays are a fixed fee you pay when you receive covered care like an office visit or pick up prescription drugs. A deductible is the amount of money you must pay out-of-pocket toward covered benefits before your health insurance company starts paying. In most cases your copay will not go toward your deductible.

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