If an out-of-pocket maximum is $3,500, and you get a hospital bill for $10,000, do you only have to pay the $3,500, or the full $10k?
After you meet the deductible and out-of-pocket max, is care essentially “free” the rest of the year since you don’t have to pay out of pocket?
In: Other
The deductible tells you when the insurance kicks in. Insurance is supposed to be for the big things, not for every little cold or sneeze.
Once it kicks in, there’s copay. Insurance pays 80%, you still have to pay 20%, they don’t cover the full amount. Up until your 20% portion adds up to the maximum out-of-pocket, you pay that 20%.
Then they pay 100%.
So, with your example, let’s say $500 deductible, $3500 max out-of-pocket, and $10,000 hospital bill.
You pay $500. Remaining bill is $9500.
You pay 20% of $9500 = $1900. Insurance pays 80% of $9500 = $7600.
The bill is paid, because $1900 + $7600 = 9500.
And you still have $3500 – $1900 = $1600 of your max out-of-pocket.
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