The out-of-pocket coinsurance is the maximum amount the individual pays after the deductible is met. For example, an individual on the PPO would pay their deductible of $1,000, then 50% of the allowed amounts up to the out-of-pocket coinsurance maximum. For the individual, this out-of-pocket coinsurance maximum amount is $1,500.
In other words, on the PPO, an individual will pay the $1,000 deductible, then their portion of allowed amounts up to $1,500 for a total out-of-pocket of $2,500 (see equation below).
Deductible | + | Out-of-Pocket
Coinsurance Maximum | = | Total Out-of-Pocket |
$1,000 | $1,500 | $2,500 |
On the PPO, a family will pay the $1,000 deductible for up to 3 family members, then their portion of allowed amounts up to $4,500 for a total out-of-pocket of $7,500 (see equation below).
Deductible | + | Out-of-Pocket
Coinsurance Maximum | = | Total Out-of-Pocket |
$3,000
(1,000 x 3 family members) | $4,500 | $7,500 |