Meet Maya. Her plan looks like every other plan: a , , and a . count toward the out-of-pocket max but not the deductible. Watch what those numbers do to four real bills.
Maya's annual checkup counts as , so the plan picks up the whole bill. She pays $0, and her hasn't even come into play yet.
Deductible after this visit: $0 of $2,000. Out-of-pocket total: $0 of $6,000.
Her prescription comes with a flat $50 . Copays don't touch the deductible, but each one counts toward her .
Deductible after: $0 of $2,000. Out-of-pocket total: $50 of $6,000.
An urgent-care visit bills at $3,000. Maya pays the first $2,000 herself, which finishes off her . On the remaining $1,000 she owes 20% , or $200. The plan covers the last $800.
Deductible after: $2,000 of $2,000, now met. Out-of-pocket total: $2,250 of $6,000.
From here you stop paying full price. Every bill now splits with the plan.
This isn't a second insurance. It's your share of one bill. Once your deductible is met, every bill splits this way until you reach your out-of-pocket max.
Then the big one: a $22,000 procedure. Her deductible is met, so her 20% works out to $4,400 on paper. She actually pays $3,750, the last dollars of her . After that, the plan pays 100% of everything.
Deductible after: $2,000 of $2,000. Out-of-pocket total: $6,000 of $6,000, max reached.
You've hit your yearly ceiling. The plan pays 100% for the rest of the year. You owe nothing more.
Maya's care billed at $25,300 this year. She paid $6,000, her out-of-pocket max, and the plan covered the other $19,300.
Illustrative example. Amounts are simplified to explain how a plan works, not a quote or a specific policy.