The deductible is the amount an individual must pay out of their pocket before Insurance will share the
cost. The coinsurance is a percentage of total charges that YOU and the insurance company pay for
covered services after the deductible is met. The out of pocket maximum (OOPM) is anything spent out
on your own pocket (not premium) and it is the most that an individual or family will spend out of their
own pocket in 1 calendar year (or plan year).
Scenario – John Doe’s health insurance plan has a deductible of $2,000, 20% coinsurance & $4,000 out of
pocket maximum (OOPM). He breaks his leg and need a cast and physical therapy. Total charges after
any network savings is $6,000. He will pay the deductible right away – $2,000. John and the insurance
company will split the remaining balance (coinsurance)- 20/80. His 20% is $800, bringing the total out of
pocket to $2,800. John’s Physical Therapy appointments will be split 20/80 until the total out of pocket hits
$4,000. If/When the OOPM is met, all covered charges will be covered by the plan.
**deductible & out of pocket maximum totals grow together. **