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What is coinsurance in health insurance?

“To sum it up…”

  • Coinsurance is the consumer’s share of the agreed insurance benefit
  • Coinsurance occurs after the customer pays the deductibles
  • Deductibles are the key to turn on insurance payments and coinsurance
  • Copays, deductibles, and coinsurance are out-of-pocket expenses for purposes of the overall annual limit
  • Network resources get greater coinsurance than outside services

Health insurance is different from other insurance. The customer must pay premiums, then pay until they exceed a deductible, and finally pay coinsurance. All along the way, most services have a copay for each usage. It is important for consumers to understand coinsurance and avoid medical bills despite having insurance.

Comparison shopping is an excellent tool for assessing the true costs of health insurance. One can focus on the features that are most likely to have a financial impact.

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Coinsurance is the Coverage for Benefits

A piggybank with a stethoscope


Coinsurance is the agreed percentage of a covered cost that the insurer and the policyholder must pay. Coinsurance is the agreed insurance coverage called for in the plan, such as 80 percent of medical services costs.

The consumer must first reach the deductible threshold or minimum to get these benefits from the policy. Coinsurance varies with whether the patient uses network resources.

The Costs Concepts in Health Insurance

When trying to determine the costs of healthcare, it is not enough to consider the monthly premium. The true costs of the insurance include the amounts that the consumer must pay.

Copays and coinsurance are usually a big part of the expenses. Out-of-pocket costs for medical services and some other expenses count toward the deductible amount required in the plan. The deductible is important because it turns on the insurance payments.

Costs and Cost-sharing


The below-listed descriptions cover the basic costs and forms of cost sharing.

– Premiums

The payments usually monthly to buy insurance. It is the basic cost of insurance coverage. The Affordable Care Act requires insurance coverage; therefore, everyone must have a contract for health insurance, and premiums are the basic price consumers pay. Consumers must pay the premium to keep coverage. In employer-sponsored plans, the employer pays a share of the premiums.

– Copays

Small fees that medical service providers can charge for a service. This fee is due when consumers use the particular service. As a persistent per usage charge, copays can add up to significant amounts. The insurance policies call for this charge; under Obamacare, some valuable services do not have any additional fee.

– Deductibles

The amounts consumers must pay each year before insurance companies begin to pay the higher parts of their agreed shares. Once past the deductible threshold amount, the insurance company begins to pay its contract share of the covered benefits. Usually, in a percentage, the customer, and company share the costs of a service.

– Coinsurance


A charge for a medical service that requires a shared cost divided between the customer and the insurance company on an amount or a percentage basis.

Coinsurance occurs after the customer passes the deductible threshold. Most often expressed as 80 percent to 20 percent, it is standard in Medicare Part B.

– Out-of-Pocket Expenses

The charges for medical services beyond copays that consumers must pay. When using in-network services of an HMO or PPO plans, these charges are subsidized or lower than market rates.

Customers must pay these charges until they pass the deductible threshold. Once past the deductible amount, the insurance money starts to flow for the patient’s medical expenses.

Obamacare Maximum Out-of-pocket Expenses


The maximum out-of-pocket expense is a limit that works in the customer’s favor. Once past the out-of-pocket limit, the insurance company must pay 100 percent of the costs of an essential benefit. The service or procedure must be medically necessary and not, for example, a cosmetic procedure.

  • Individual 2016 out-of-pocket limit is $6,850.
  • Family 2016 out-of-pocket limit is $13,700.
  • Family 2017 out-of-pocket limit is $14,300.
  • Individual 2017 out-of-pocket limit is $7,150.

Counting Deductible Expenses

Copays and premiums do not count towards the deductible threshold. The costs of medical services do count. Before reaching the deductible threshold patients must pay their medical services bills. The exception to this is the free Obamacare prevention and early detection essential health benefits included in every policy.

These include exams, some vaccines, health screenings, and wellness visits. These were added to Medicare benefits too, Original Medicare and Medicare Advantage became more valuable for these no-cost extra benefits.

The Battle with Out-of-pocket Expenses


Health insurance today can be described as a battle between the consumer and the insurance companies over out-of-pocket costs.

The customer seeks to avoid them and keep costs low, the insurers understand that their path to profits to shift some costs to the consumer while making the overall package affordable.

HMO plans keep costs lower by restricting choices of provider to network resources. PPO plans keep costs low by allowing outside resources but paying a much lower rate of coinsurance.

Obamacare Prevention Benefits

Obamacare made an exception to the rule that benefits only come after the customer pays the deductible amount. Obamacare provides a wide range of important prevention and wellness services at no additional charge to the policyholder. These are benefits with no cost sharing.

Coinsurance and Metal Bands

A man writing a numerical list

The four types of Obamacare policies correspond to coinsurance rates.

  • Platinum has a 90 percent average coinsurance rate leaving 10 percent for the consumer. It has the lowest, most easily reached deductibles.
  • Gold has a coinsurance split of 80 percent to 20 percent; it has low deductibles.
  • Silver divides the cost-sharing 70 percent to 30 percent; with moderate deductibles, some plans are high and can pair with Health Savings Accounts.
  • Bronze is the minimum for qualified coverage at 60 percent to 40 percent for consumer payment. It has high deductibles that are not likely reached without a significant medical event.

Deductibles and Premiums

The insurance companies require deductible payments as a way of offering protection with lower premium payments. High deductibles match with low premiums.

The deductible must be paid before the insurance company must pay their share of the insured benefits.

Copays are fixed fees for medical services that consumers must pay. Copays do not count towards the deductible amount.

Obamacare Has a Deductible Maximum


The Affordable Care Act establishes maximums for deductibles and out of pocket expenses. The below-listed items describe the deductible rules for 2017.

  • Maximum individual 2016 deductible cost is $6850.
  • Maximum family 2016 deductible costs is $13,700.
  • Maximum 2017 deductible individual is $7,150.
  • Maximum 2017 deductible for a family is $14,300.

Counting Out-of-Pocket Expenses


The federal government sets the overall limit on out-of-pocket expenses set for qualified health plans each year for network services. Plans each have a limit for out-of-pocket network services. The key is in the phrase network services. Money spent on outside resources may not count towards the plan limit.

This uneven count may cause people using a PPO to pay more out-of-pocket than people using an HMO. The HMO does not allow outside resources, and the plan limit is more reachable than the PPO.

  • A network is the group of doctors, specialists, and medical care facilities that have agreements with the insurance company. They agree to provide services at an agreed price to the members of the insurer’s plan or plans.
  • ”In-Network” describes the use of network doctors by plan subscribers. This is the most cost effective situation for the insurer and the insured.
  • ”Out-of-Network” services are all other doctors and specialist which a plan member might use. By going outside of the network, the consumer will pay more in coinsurance. In many cases , the consumer must pay the entire amount.

Using Outside Services

Preferred Provider Organization plans permit patients to use outside doctors and specialists. The insurance company pays a different share when patients go outside of the provider network. These cost sharing arrangements are coinsurance.

The customer and the insurance contribute different shares on the basis of network resources. The insurance agreement calls for a higher payment from the customer when using outside doctors and specialists.

Coinsurance is Shared Responsibility for Benefits

In health insurance, coinsurance is the amount that represents the split between the customer and the insurance company to pay for any covered benefit. This applies once the customer passes the deductible amount of out-of-pocket spending and until the policy reaches the annual limit on out-of-pocket expenses.

Maximum Benefits


Once past the deductible and the out-of-pocket limit, the insurance must pay 100 percent of the covered benefit using in-network resources.

On any service, the insurance company pays its share, and the consumer pays his or her share. Once past the deductible and overall limit, the insurance pays the entire amount.

Comparison shopping is a great way to find the true value of the policy. The premiums only describe part of the costs, and cost sharing only occurs after the consumer spends the deductible threshold.

Having health problems doesn’t mean you have to go broke. Enter your zip below and discover various healthcare plans, from low-deductible to high-premium, and find one that fits your life and budget.

  1. https://www.healthcare.gov/glossary/co-insurance/
  2. http://obamacarefacts.com/health-insurance-networks/
  3. http://obamacarefacts.com/health-insurance/deductible/
  4. http://obamacarefacts.com/obamacare-individual-mandate/
  5. https://www.healthcare.gov/choose-a-plan/your-total-costs/
  6. http://obamacarefacts.com/health-insurance-premium-and-cost-sharing-explanation/
  7. http://obamacarefacts.com/health-plan-types-hmo-ppo/
  8. http://obamacarefacts.com/obamacare-preventive-care/
  9. http://obamacarefacts.com/insurance-exchange/health-insurance-plans/
  10. https://www.healthcare.gov/why-coverage-is-important/pay-less-before-meeting-deductible/
  11. http://obamacarefacts.com/out-of-pocket-maximums-and-deductible-limits-for-2017-health-plans/
  12. http://obamacarefacts.com/health-insurance/out-of-pocket-maximum/
  13. https://www.healthcare.gov/choose-a-plan/plan-types/
  14. https://www.healthcare.gov/glossary/in-network-coinsurance/
  15. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/