Coinsurance Maximum definition

Coinsurance Maximum means a specified dollar amount of Coinsurance Incurred by a Participant, as set forth in the Summary of Benefits, for covered services in a Benefit Period. (Refer to the Summary of Benefits for the period selected by the Plan.)

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Coinsurance Maximum means the maximum dollar amount in the form of Coinsurance that a Member will be required to pay in a given Benefit Period for Covered Services, as set forth on the Schedule of Benefits. The Coinsurance Maximum does not include the following: (i) Deductibles; (ii) Copayments; (iii) amounts above a specific Benefit Limit as set forth in the Certificate and/or Schedule of Benefits; (iv) amounts above the Lifetime Benefit Maximum as set forth on the Schedule of Benefits; (v) amounts above the PPO’s Non-Preferred Provider Fee Schedule Amount; and (vi) amounts for non-Covered Services. This means that the Member, not the PPO, will be responsible for payment of all these amounts noted above, even if the Coinsurance Maximum has been reached. As item (v) can result in substantial financial responsibility for the Member, please refer to Exhibit 2 for an illustration of potential Cost Sharing when Non-Preferred Providers are utilized. Amounts paid toward satisfaction of the Coinsurance Maximum amounts for Covered Services obtained from either Preferred or Non-Preferred Providers accrue toward satisfaction of both Coinsurance Maximum amounts as set forth on the Schedule of Benefits. The Coinsurance Maximum applies to each Member or Family Unit subject to any family Coinsurance Maximum set forth on the Schedule of Benefits.

Coinsurance Maximum means the maximum amount to be paid by an Insured as Coinsurance for Covered Services per Calendar Year. Please refer to Attachment A Benefit Schedule, for specific information on how the Coinsurance Maximum for your Plan is determined. The following are not included in the Calendar Year Coinsurance Maximum:

Examples of Coinsurance Maximum in a sentence

• Coinsurance incurred toward the Preferred Provider Coinsurance Maximum will not be applied to the Non-Preferred Participating/Non-Preferred Provider Coinsurance Maximum.

• This means that the Member will be financially responsible for the difference between the PPO’s Non-Preferred Provider Fee Schedule Amount and the Non-Preferred Provider’s billed charge, even if the Coinsurance Maximum has been reached.

• Deductible and Coinsurance amounts for family members that did not satisfy the individual limits will not be refunded in the event the family Deductible or family Coinsurance Maximum is met by three (3) separate family members.

• Coinsurance Maximum amounts do not include: ♥ Charges by a provider in excess of the Maximum Allowable Amount, ♥ Amounts paid by Members a Benefit Reductions, and ♥ Deductibles or any Copayments.

• Annual Employer Funding to HSA $700 for individual $1,400 for family Coinsurance Amounts (Percentage) Plan pays 100% Plan pays 80% Member pays 0%*After deductible Member pays 20%*After deductible Coinsurance Maximum (per calendar year) None None Annual Out-of-Pocket Maximum $2,250 individual $4,500 individual Includes deductible, flat-dollar copays (medical and prescription) and coinsurance combined.

• Coinsurance incurred toward the Non-Preferred Participating/Non-Preferred Provider Coinsurance Maximum will also be applied to the Preferred Provider Coinsurance Maximum.

• As Described in Section 1.9, when using a Non-Preferred Provider, any costs that exceed the PPO’s Non- Preferred Provider Fee Schedule Amount are not included in the Coinsurance Maximum.

• January 1, 2013 After $2,000/$4,000 Deductible met Additional $2,000 Individual / $4,000 Family Coinsurance Maximum (Includes Rx) Lifetime Maximum - Unlimited *Town of Greenwich will contribute $1,250/$2,500 towards deductibles **Deductibles and Co-Insurance are calculated on a calendar year ***In Network Pre-Cert / Prior Auth.

• The Out-Of-Network Level Of Benefits Cost-Share Maximum is considered to be met for a Member if his or her individual Out-Of-Network Level Of Benefits Copayment Maximum and Coinsurance Maximum are met by the Copayment and Coinsurance amounts paid by that Member for services paid at the Out-Of-Network Level Of Benefits.

• Annual Employer Funding to HSA $700 for individual $1,400 for family Coinsurance Amounts (Percentage) Plan pays 100% Plan pays 80% Member pays 0%*After deductible Member pays 20%*After deductible Coinsurance Maximum (per calendar year) None None Annual Out-of-Pocket Maximum $2,250 individual $4,500 individual Note: The illustrative rates for the Blue Cross Blue Shield PPO change effective January 1 of each benefit year.