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This example shows how deductibles add up throughout the year. In the example, the deductible is $250 per individual, the plan's co-insurance is 90%, and the employee's co-insurance is 10%. Routine immunizations are not covered by insurance and doctor office visits are subject to the deductible. The out-of-pocket maximum is $2,000. Service costs are only for illustration and are not based on any plan or geographic region.
|
In-network Negotiated Fee |
Deductible Employee
Pays |
10% Co-insurance Employee Pays after Deductible |
Employee’s Total Cost |
…Then Plan Pays |
| Service 1: Doctor’s office visit |
$120 |
$120
(assumes deductible is not met) |
$0 |
$120 |
$0 |
| Service 2: Routine immunization |
$300 |
$0
(costs for services that are not covered do not count towards deductible or out-of-pocket maximum) |
$0 |
$300 |
$0 |
| Service 3: Inpatient surgery |
$15,000 |
$250 - $120 = $130
(the remainder of deductible) |
$1,487
($15,000 - $130 = $14,870, x .10) |
$1,617 |
$13,383 |
Service 4: Outpatient knee
surgery |
$10,000 |
$0
(deductible was met) |
$1,000
($10,000 x .10) |
$1,000 |
$9,000 |
| Subtotal (subject to out-of-pocket maximum) |
|
|
|
$2,737 |
$22,383 |
| Total Cost (after out-of-pocket maximum) |
$25,420 |
|
|
$2,300
($2,000 out-of-pocket maximum plus $300 non-covered service) |
$23,120($22,383 plus $737, amount over out-of-pocket maximum) |
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