Help understanding the difference between coinsurance limit and out of pocket max

Seeking Help
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My insurance has a deductible of $1,800, a coinsurance limit of $3,500, and an out-of-pocket maximum of $9,000.

Can someone explain what I will have to pay after reaching the coinsurance limit?

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Thanks for posting! If there’s a medical emergency, call 911. Also, including your age, state, and income can help people give better advice. Having your EOB handy is useful too.

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Do you have a $3,700 deductible for prescriptions?

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You will pay out of pocket at least $1,800 (your deductible) and no more than $9,000 (your out-of-pocket max) in a year. For each medical service, you’ll share a percentage of the cost (coinsurance), but no more than $3,500 total in coinsurance costs.

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@Indy
It seems like there might be a $3,700 deductible for prescriptions. Otherwise, the numbers don’t add up to the $9,000 out-of-pocket max.

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Ashwin said:
@Indy
It seems like there might be a $3,700 deductible for prescriptions. Otherwise, the numbers don’t add up to the $9,000 out-of-pocket max.

Where did you get the $3,700?

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@Indy
The out-of-pocket max is $9,000, with a $1,800 deductible and a $3,500 coinsurance limit. There might be an additional prescription deductible of $3,700 to explain the gap.

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Ashwin said:
@Indy
The out-of-pocket max is $9,000, with a $1,800 deductible and a $3,500 coinsurance limit. There might be an additional prescription deductible of $3,700 to explain the gap.

Is the $3,500 coinsurance limit per charge, or total? For example, if after reaching the deductible, you have a 50% coinsurance on a $10,000 charge, you’d pay only $3,500 instead of the full $5,000. The next charge would be subject to regular coinsurance until you hit the out-of-pocket max.

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Do you have any copays?

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Hart said:
Do you have any copays?

I think it’s copays. I’m going to call on Monday to confirm.

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It can be confusing! I’d recommend looking at your healthcare needs from last year and comparing that with your coverage. Also, double-check your network providers to make sure the doctors you want are covered.

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