Glossary of Health Coverage and Medical Terms Page 6 of 6 How You and Your Insurer Share Costs - Example Janes Plan Deductible: $1,500 Coinsurance: 20% Out - of - Pocket Limit: $5,000 Januar y 1 st Beginning of Coverage Period December 31 st End of Coverage Period Her plan pays 0% Jane hasnt reached her $1,500 deductible yet Her plan doesnt pay any of the costs. Office visit costs: $125 Jane pays: $125 Her plan pays: $0 Jane pays 100% more costs Jane pays 20% Her plan pays 80% Jane reaches her $ 1,500 deductible , coinsurance begins Jane has seen a doctor several times and paid $1,500 in total , reaching her deductible . So h er plan pays some of the costs for her next visit. Office visit costs: $125 Jane pays: 20% of $125 = $2 5 Her plan pays: 80% of $ 125 = $ 100 more costs Jane pays 0% Her plan pays 100% Jane reaches her $5,000 out - of - pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her cove red health care services for the rest of the year. Office visit costs: $125 Jane pays: $0 Her plan pays: $125 PRA Disclosure Statement: Accordin g to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it display s a valid OMB control number. The valid OMB control number for this information collection is 0938 - 1146 . The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4 - 26 - 05, Baltimore, Maryland 21244 - 1850.