Deductibles, Coinsurance, and Out-of-Pocket Maximums: A Guide for FIC’s PPO Plans

Nov 24, 2008

The below information applies to PPO 1, PPO 2, and PPO 3, not to the HD plans. Remember, when you use an in-network provider, your coinsurance and deductibles are applied to the provider’s negotiated, in-network rate, not the “retail” price.

  • Deductible (in-network): A deductible is the amount you pay out-of-pocket before your insurance starts covering you. There is no deductible for in-network doctor visits. The deductible applies only to facility (hospital) visits, both in- and out-patient. While you accrue toward your facility deductible, you will pay the negotiated rate, not the retail amount, for services. There is also a separate deductible for out-of-network services.
  • Out-of-pocket maximum (in-network): There’s a cap to how much you would ever have to spend on in-network facility (hospital) visits per year. Once your deductible and coinsurance payments reach this amount in a given year, FIC covers 100% of the in-network hospital charges for the rest of that year.
  • Coinsurance (in-network): Coinsurance is the percent you pay (of the negotiated rate) after meeting your deductible; FIC pays the remainder of the allowable expense. For x-rays and imaging, there’s coinsurance and no deductible. For facility (hospital) visits, both in- and out-patient, you first pay the deductible, and after that you pay only coinsurance. There is also a separate coinsurance and deductible for out-of-network expenses.
  • Imaging (in-network): Imaging includes x-ray, MRI, CAT scan, EKG, ultrasound, and other services. It is covered with coinsurance, and there is no deductible. The amount you spend toward the imaging coinsurance is not counted toward your out-of-pocket maximum.  For imaging that takes place during a facility (hospital) stay, the cost is covered as part of the facility visit (which has an out-of-pocket max).