Individual Deductible - The amount you personally must pay out-of-pocket for covered services before your insurance starts to contribute. Everyone on your plan may have a different individual deductible.
Example: If your individual deductible is $1,000, you must pay that amount before your insurance covers a portion of your care.
Individual Deductible Remaining - How much you personally still need to pay before your insurance begins helping with costs.
Example: If your deductible is $1,000 and you've already paid $600, your remaining deductible is $400.
Family Deductible - The total combined amount your family must pay before insurance starts contributing toward care for anyone on the plan. Once this is met, everyone’s deductible is considered satisfied — even if some family members
haven’t met their individual deductibles.
Example: If your family deductible is $3,000, once the family has paid that total (even if it's split unevenly), insurance coverage kicks in for everyone.
Family Deductible Remaining - The remaining amount your family needs to pay (collectively) before insurance starts covering costs for any member.
Example: If your family deductible is $3,000 and you've collectively paid $2,200, the remaining deductible is $800.
Individual Out-of-Pocket Maximum - The most you’ll personally pay in a year for covered services, including your deductible, co-pays, and co-insurance. After reaching this amount, your insurance pays 100% of covered costs for the rest
of the year.
Example: If your out-of-pocket max is $6,500, and you’ve paid that through a combination of deductible, co-pays, and co-insurance, insurance covers all eligible expenses for the rest of the year.
Family Out-of-Pocket Maximum - The most your family will pay in total during the year. Once this limit is reached, insurance covers 100% of covered services for everyone on the plan.
Example: If your family out-of-pocket max is $13,000 and your family hits that amount collectively, insurance pays the full cost for any further covered services.
Co-Pay - The fixed amount a patient pays for a health care service, determined by the insurance company for a specific service, paid for at the time of service.
Example: If your co-pay is listed as $25, you will pay $25 for your health service, after your deductible has been covered. Your insurance plan will pay the remaining balance of the bill.
Co-Insurance - The percentage of a medical charge that a patient pays after a deductible has been met, with the rest paid by your health insurance plan.
Example: If your co-insurance is listed as 10%, you will pay 10% of the payment that has already been made by your insurance carrier for the claim, after your deductible has been covered.
Visit Limits - Some insurance plans only allow a certain number of visits per service per year (e.g., 20 physical therapy visits). These are set by your insurance plan, and once you exceed that number, additional visits may not be covered
unless authorized.
Example: If your plan covers up to 20 physical therapy visits per year, anything beyond that may require approval or result in an out-of-pocket charge.
Remaining Visit Limits - The number of covered visits you have left for the year. Once this hits zero, you may be responsible for the full cost unless additional visits are approved by your insurance.
Example: If you've used 12 of your 20 covered physical therapy visits, your remaining visit limit is 8.
