A co-insurance (or “percentage participation”) clause is designed to provide a structure whereby the insured is responsible for a portion of their own medical costs. This is usually set up on a percentage basis. For example, if your plan provides for an 85/15 sharing of cost, you will be responsible for 15 percent of the eligible costs after the deductible has been satisfied. The plan will cover the remaining 85 percent. Note: This is only an example; depending on the company, percentages can significantly vary. Provisions of 80/20, 90/10 and others are also commonly employed.

In addition, most major medical plans include a cap as to the amount much a member must pay per year in accordance with the terms of the agreement. This is designed to protect the insured so that he | she is not left financially devastated by an illness or accident requiring extensive treatment(s.) As with other terms of the plan, though the amount of the cap will vary, it typically will remain within the $1,000 to $3,000 range.

After this out -of -pocket limit has been met, your carrier will typically cover all expenses until your coverage limit is completely exhausted.