What Is Coinsurance for Health Insurance?
Coinsurance is the percentage of health care services costs you must pay out of pocket after you’ve reached your policy’s deductible.
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- Coinsurance is the percentage of health care costs you must pay after you’ve met your deductible.
- The insurance company generally pays a greater percentage of any medically necessary healthcare service, and you pay the rest.
- Health plans with low premiums tend to have higher coinsurance costs.
- Federal law limits annual out-of-pocket costs for marketplace health plans.
- If you meet your plan’s annual out-of-pocket maximum, you no longer have to pay coinsurance for that year.
How Coinsurance Works
Coinsurance is your out-of-pocket expense for a covered medical or health care cost after the deductible, which generally renews annually, has been paid on your health care plan. It is one of several health insurance costs, including your premium, deductible, and copayments.
Generally expressed as a percentage amount and outlined in your policy documents, coinsurance allows you to share the cost of the insured service with the insurance company—your insurance company pays the portion of the cost of the service that is insured, and you pay the remainder.
The deductible is the amount you must pay out of pocket every plan year before your health insurance kicks in.1 A copayment is a fixed dollar amount you must pay for health care services after you’ve paid your deductible, such as a $25 copay per visit to your primary care doctor.
Coinsurance only applies once you’ve paid your deductible. Once you’ve met your deductible for the year, your coinsurance percentage will be charged to you, along with any copays that apply.
Coinsurance amounts typically aren’t split evenly between you and your insurer. The insurance company generally bears a higher burden, paying the majority of the covered cost (the greater percentage) of a covered health care service.
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The first number in a coinsurance split is what your insurer pays and the second number is what you pay. Coinsurance is typically applied to the insurer’s allowed amount for a covered healthcare service, which is the maximum amount the plan will pay for that expense.2
Common coinsurance divisions are 70/30 or 80/20—your insurance company would pay either 70% or 80%, and you would pay the remaining 20% or 30%, respectively, out of pocket, after the deductible is met.
You’ll continue to pay your coinsurance throughout the year unless you’ve hit your out-of-pocket maximum. Once you reach your out-of-pocket maximum, you won’t be charged any costs for health insurance aside from premiums, out-of-network services, and any other costs that your plan doesn’t typically cover.34
Example of Coinsurance
Say you met your deductible in the spring and, in the fall, you break a finger and go to the emergency room. Your bill is $2,000 (within the allowed amount), and your coinsurance is 80%/20%, which means you’re responsible for 20% of the bill. You’ll pay $400.
That $400 is known as your “out-of-pocket” expense. The insurance company, paying the majority of the cost at the higher percentage, would pay the remaining $1,600.3
In general, health insurance plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.2
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Health Insurance Marketplace Coinsurance
Marketplace health plans come in four categories. These categories define the percentage of costs the insurance company pays for your health care needs and the percentage of coinsurance you must pay. These percentages kick in once the deductible has been met.
- Bronze: With a bronze plan, you pay 40% coinsurance, and the insurance company pays 60%. Although bronze plans offer the lowest monthly premiums, they have high deductibles and the highest coinsurance percentage.
- Silver: Silver plans require you to pay 30% coinsurance, while the insurer pays 70% of costs. Silver plans offer more moderate health care costs than bronze plans, with lower deductibles and moderate premiums.
- Gold: Gold plans require you to pay 20% coinsurance, while the insurance company pays 80% of the costs. Although these plans feature low deductibles and out-of-pocket costs, they have higher monthly premiums than bronze or silver plans.
- Platinum: These plans pay 90% of your health care costs and you pay 10%. They offer very low deductibles but have the highest monthly premiums.5
Coinsurance vs. Copayment
The terms “coinsurance” and “copayments” sound similar, but they are two very different health care costs.
|Paid after meeting your deductible||Paid after meeting your deductible|
|Percentage of health care cost||Fixed dollar amount|
|Fixed percentage for all services||Can vary by service|
|Subject to Marketplace out-of-pocket limits||Subject to Marketplace out-of-pocket limits|
Coinsurance is a percentage of costs you must pay after meeting your deductible. Typically, health plans with the lowest monthly premiums have the highest coinsurance costs.3
A copayment is a fixed dollar amount you must pay when receiving health care services after meeting your policy’s deductible. Unlike coinsurance, copayment amounts can vary by service.6
With marketplace policies, both coinsurance costs and copayments are subject to annual out-of-pocket limits.
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The Bottom Line
Coinsurance is a standard feature in health insurance plans. The cost is required after paying your deductible, except for services fully covered by your plan, such as preventive care. Marketplace health insurance plans cap annual out-of-pocket coinsurance costs as well as deductible and copayment costs.
Choosing a health plan requires striking a balance between what you can afford to pay in premiums and how much you can afford to pay in health care costs. Plans that offer low premiums typically require you to pay a higher percentage of coinsurance, while plans with higher premiums pay a higher percentage of health care costs.
Frequently Asked Questions (FAQs)
What is Medicare coinsurance?
Medicare Part A’s coinsurance varies. For example, durable medical equipment comes with a 20% coinsurance, while Medicare-approved inpatient respite care comes with a 5% coinsurance.7 Medicare Part B’s coinsurance is typically 20%.8 Medicare Advantage, Part D, and Medigap coinsurance amounts vary by plan.
What is the difference between deductible and coinsurance?
Your deductible is your out-of-pocket cost before your health insurance begins to cover costs. After you’ve reached your deductible, your coinsurance kicks in, and that becomes the amount you’re expected to pay out-of-pocket.2
What does 80% coinsurance mean?
Typically, 80% coinsurance means that, once you meet your deductible, your insurer is responsible for 80% of covered medical bills and you’re responsible for 20%. If you have a $2,000 bill and you’ve met your deductible, 80% coinsurance means your insurer would pay $1,000 and you’d pay $400.
Is coinsurance good or bad?
Coinsurance is a good thing to have because it makes you responsible for a fraction of a covered medical bill instead of the entire amount.