Don't understand how deductibles, coinsurance and maximum out-of-pocket costs work? You aren't the only one.
What’s a Deductible?
Your deductible is the amount you pay for covered health care services before your insurance starts to pay. For example, if your deductible is $1,200, you must pay 100% of the first $1,200 of eligible medical costs before your TRS-ActiveCare plan starts to pay.
Your deductible depends on which TRS-ActiveCare plan you're enrolled in and if you have any dependents. If you don't know what your deductible is, find it here.
Not every cost counts toward your deductible.
| Costs that count toward your deductible: | Costs that DON'T count toward your deductible: |
| hospitalizations | copays |
| surgeries | services your plan does not cover |
| lab tests at in-network facilities | monthly premium |
| Office visits a copay does not cover |
Individual vs. Family Deductible
If you have a family plan, it's important to understand how deductibles and out-of-pocket limits work so you're not hit with surprises.
Every covered family member has an individual deductible and maximum out of pocket, or MOOP. The whole family also has a deductible and MOOP.
With all TRS-ActiveCare plans, individuals need to meet their deductible before the plan begins to pay coinsurance. They don't have to meet the family deductible for coverage to start.
Claims that count toward a person's deductible also count toward the family deductible. Once a person meets their deductible, they pay coinsurance and copays, which don't count toward the family deductible.
After any combination of family members meets the family deductible, the entire family pays only coinsurance and copays for medical care and prescriptions for the rest of the plan year.
What’s Coinsurance?
Coinsurance is the portion you pay for services after you meet your deductible. Your coinsurance depends on the TRS-ActiveCare plan you're enrolled in:
- TRS-ActiveCare Primary – 30% after deductible
- TRS-ActiveCare Primary+ - 20% after deductible
- TRS-ActiveCare HD – 30% after deductible for in-network costs, 50% after deductible for out-of-network costs
You'll pay your coinsurance for covered medical expenses until you meet your MOOP.
Maximum Out of Pocket
Your MOOP is the maximum amount you pay each year for medical costs. After reaching your MOOP, the plan pays 100% of the costs for covered services. If you have a family plan, MOOPs work the same way as deductibles.
An individual's deductible, copays and coinsurance count toward both individual and family MOOPs. After any combination of family members meets the family's MOOP, the plan covers the family's medical care and prescriptions at 100% for the rest of the plan year.
Resources
Personal Health Guide
Talk to a Personal Health Guide, 24/7. Call 1-866-355-5999 or chat in the BCBSTX App. A PHG can help you with your wellness needs, find you a provider, make an appointment, get claims information, do cost comparisons, and more.