Embedded coinsurance maximum introduced for 2015

Beginning Jan. 1, 2015, group plan benefits may include something new — an embedded coinsurance maximum.

What exactly is an embedded coinsurance maximum?

Coinsurance is a percentage of the cost of a service that the member is responsible for paying. A coinsurance maximum provides a maximum dollar amount that the member will pay for coinsurance. Once the coinsurance maximum is reached, the member will no longer pay coinsurance for the rest of the benefit year, with the exception of certain services that are exempt from the coinsurance maximum.

The coinsurance maximum is considered to be “embedded” because one member on a two-person or family contract cannot contribute in excess of the individual maximum amount. The embedded coinsurance maximum will count toward the out-of-pocket maximum along with the deductible and all other cost-sharing, such as medical or prescription drug copays.

You’ll know whether a member has an embedded coinsurance maximum by looking at the medical benefits description page on web-DENIS. If the member has a coinsurance maximum, you’ll see “coinsurance maximum” listed, along with the specific dollar amounts for that contract and the list of exclusions noted below.

Services that may be exempt from the coinsurance maximum include:

• Deductible amounts
• Services with a flat dollar copayment
• Diabetic supplies
• Durable medical equipment
• Elective abortion (if covered)
• Infertility services
• Male mastectomy
• Male sterilization
• Orthognathic surgery
• Prosthetics and orthotics
• Reduction mammoplasty
• Temporomandibular joint dysfunction
• Weight reduction procedures

If you have any questions, contact your provider consultant.