What Is Coinsurance?

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DEFINITION
Coinsurance is the percentage of health care services costs you must pay out of pocket after you’ve reached your policy’s deductible.

With health insurance, coinsurance is the percentage of health care costs the policyholder must pay. Coinsurance applies after the policyholder has paid their annual deductible. This is often a percentage that applies to all health services except preventive services that are fully covered by a health plan.

Key Takeaways

  • Coinsurance is the percentage of health care costs you must pay after you’ve met your deductible.
  • 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.

What Is Coinsurance?

Coinsurance is the percentage of health care services costs you must pay out of pocket after you’ve reached your policy’s deductible.

For example, you may choose a health insurance policy that has a $1,500 annual deductible and requires you to pay 30% coinsurance. You’ll have to pay the first $1,500 in health care costs each plan year before your insurance starts sharing the costs.

So, after reaching your deductible, if you have a surgery that costs $10,000, you’ll pay 30% of the costs, which is $3,000.

In general, health care insurance plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.

Understanding Coinsurance

Health insurance policies require you to make a monthly payment—the premium—to keep the coverage in force. However, the monthly premium isn’t all you’ll have to pay, and coinsurance is just one of the additional costs associated with a health care plan. It’s important to understand what your plan will cover, what you are responsible for, and how each cost factor—including your coinsurance—will apply.

Health Insurance Costs

Besides your monthly premium, health insurance has three additional costs.

Deductible

The deductible is the amount you must pay out of pocket every plan year before your health insurance kicks in. Let’s say your plan year begins on January 1 and your policy has a $2,000 deductible. If you need $2,500 in health services during the plan year, you’ll have to pay the first $2,000, then your health insurance will pay the rest minus any coinsurance and copayments.

Oftentimes, health plans cover certain types of services before your deductible kicks in. For example, a plan may pay for disease management services or annual checkups. Health plans purchased through the federal government-sponsored Health Insurance Marketplace, for instance, pay for certain preventive care services such as immunizations and screening tests even if you haven’t reached your deductible.

Family health plans may have a family deductible, which applies to all covered family members, as well as individual deductibles, which apply to each covered individual.

Copayments

A copayment is a fixed dollar amount you must pay for health care services after you’ve paid your deductible. For example, a policy may require you to pay a $25 copayment every time you visit the doctor. You pay copayments directly to the service provider at the time you receive the service.

Health plans often require different copayments for different types of services. For example, you may pay a $25 copayment for doctor’s visits, a $50 copayment for specialist visits, and a $20 copayment for laboratory tests.

Coinsurance

Once you’ve paid your annual deductible, you’ll have to pay copayments and coinsurance for health services. Coinsurance is a percentage of the cost of a particular service. For instance, if your policy requires 20% coinsurance, you’ll pay $200 for a $1,000 medical procedure.

Let’s say you’ve already paid your deductible for the year and your policy requires you to pay 20% coinsurance and a $25 copayment for doctor’s visits. When you visit the doctor again, you’ll pay the $25 copayment. If the doctor charges $100 for a procedure, you’ll pay $20, and the insurer will pay the remaining $80.

Plan Categories and 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 costs. Although these plans feature low deductibles and out-of-pocket costs, they have higher monthly premiums than bronze or silver plans.

Platinum

Platinum plans pay 90% of your health care costs and you pay 10%. They offer very low deductibles but have the highest monthly premiums.

Out-of-Pocket Limits

You must make monthly premium payments to keep your coverage in place. But with Marketplace health plans, the federal government caps the annual out-of-pocket costs you will pay for coinsurance, copayments, and deductibles incurred for in-network services.

For plan year 2022, Marketplace policyholders pay a maximum of $8,700 for individual coverage and $17,400 for family coverage. So if you have individual coverage and meet the $8,700 threshold, your insurance will cover the remainder of your health costs for the rest of your policy’s plan year.

Out-of-pocket maximums do not apply to services not covered by your plan or out-of-network services.

Coinsurance vs. Copayment

The terms “coinsurance” and “copayments” sound similar, but they are two very different health care costs.

Coinsurance Copayments
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.

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.

With Marketplace policies, both coinsurance costs and copayments are subject to annual out-of-pocket limits.

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.

Article Sources

  1. Healthcare.gov. “Coinsurance.” Accessed Jan. 28, 2022.

  2. Healthcare.gov. “Deductible.” Accessed Jan. 28, 2022.

  3. Healthcare.gov. “Preventive Services.” Accessed Jan. 28, 2022.

  4. Healthcare.gov. “The 'Metal' Categories: Bronze, Silver, Gold & Platinum.” Accessed Jan. 28, 2022.

  5. Healthcare.gov. “Out-of-Pocket Maximum Limits.” Accessed Jan 28, 2022.