Understanding Coinsurance: What It Means for Your Health Care Costs

Posted: June 05, 2024

Coinsurance, like deductibles and co-pays, are different types of out-of-pocket costs you may need to pay for health care services. Understanding these different terms and how to calculate them is essential for understanding your health coverage and getting the right costs ready in advance. Coinsurance is a beneficial cost-sharing option that allows you to share medical bills with insurance providers, making your health care costs more manageable.

This guide explores how coinsurance works, how it differs from other cost-sharing requirements like copayments and deductibles and how to calculate coinsurance costs. It also provides helpful examples of the different types your insurance provider might offer, where you can find your coinsurance structure and what to enquire about.

What Is Coinsurance in Health Care?

Coinsurance is when you pay for a percentage of health costs on your own. Your insurance plan will pay the other portion of medical costs after you meet the deductible. The deductible is the initial amount your plan requires you to pay before the coinsurance kicks in.

When setting up your insurance plan, you’ll notice the coinsurance operates on a fixed ratio. This means you’ll always pay a certain percentage of a medical bill each time, rather than a fixed amount on every medical bill

What Is 80/20 Coinsurance?

80/20 coinsurance refers to when your insurance company pays 80% of the total health cost while you pay the other 20% of the amount. There are various payment structures similar to this that your insurance provider might offer.

For example, they might apply a 30/70 coinsurance payment structure, which requires you to pay 30% while the company pays 70% or 40/60 coinsurance, which leaves you responsible for 40% of the amount and the insurance company responsible for 60%. They will list the structure type in the coinsurance plan description.

What Is the Difference Between Coinsurance and Copay?

While coinsurance is a percentage of the total medical bill you pay, a copay is a set dollar amount you pay for your health care services at the time you receive care. For example, you might have a $200 copay for emergency room visits and a $20 copay for primary care physician assistance.

The main difference between the two is that the coinsurance amount will always vary, while the copayment amount will remain the same across medical bills. A copay is paid every time you fill a prescription or see your care provider. In contrast, your care provider will pay coinsurance costs only after the insurance approves the charges and calculates your percentage. Additionally, in some cases, a copay might count toward your deductible. You may only pay coinsurance after you meet the deductible.

Depending on your out-of-pocket maximum — which is the yearly limit for the money you can spend on health care costs out of pocket — you may only need to pay coinsurance costs and deductibles until you reach the out-of-pocket maximum amount. After this point, the insurance company may cover all costs for the rest of the policy term.

What Does 0% Coinsurance Mean?

One of the best coinsurance structures to have, 0% coinsurance means you can avoid contributing to the medical bill. In this case, your insurance company will pay for the entire claim. Still, it’s important to note that this coinsurance will only kick in after you’ve met your deductible.

Additionally, you must pay attention to the percentage on your Summary of Benefits. This is because sometimes they may list 0% to indicate that the insurance provider will cover 0% while you pay 100% coinsurance. Whether noticing a very high or low percentage, make sure to clarify with your insurance company about what the percentage means.

What Does 100% Coinsurance Mean?

100% coinsurance means that you are responsible for the entire medical bill even after meeting the plan deductible. This entire amount will require an out-of-pocket payment and may be ineligible for reimbursement. Only once you meet your plan’s annual out-of-pocket maximum in medical bills will the insurance company be responsible for your health care costs.

How to Calculate Coinsurance Costs?

Given that the specific dollar amount you pay for coinsurance will vary with each medical bill, you may want to understand how to calculate this amount beforehand so you know what to expect. Here are a few steps to calculating your coinsurance costs:

1. Understand your coinsurance rate: Check for your coinsurance rate in the Summary of Benefits and Coverage section of your plan. Check if it is the same across health services or if they vary based on the type of service you receive. Keep in mind that these costs directly correlate to your out-of-pocket maximum. Once the dollar amount in coinsurance costs reaches the out-of-pocket maximum, your insurance provider will pay the rest of your eligible coverage.
2. Establish how much your deductible is: Depending on your deductible, you’ll have to pay your medical bills in full until you reach the amount on your deductible. Only after this may you start paying coinsurance.
3. Check for in-network provider discounts: In some cases, using an in-network provider listed by your insurance company may allow you to receive discounts on the total cost of the health care service. Take this amount into account when determining the total medical bill cost. You’ll find this listed as an “allowed amount” in the Explanation of Benefits section of the plan. The government makes it essential for health plans to be transparent about pricing for covered services.
4. Calculate your coinsurance amount: Start by converting your coinsurance percentage into a decimal figure. You can do this by moving the decimal point two spaces forward. For example, 20% would be 0.20 and 50% would be 0.50. Multiply your decimal figure by the network-approved amount you established in the previous step. Keep in mind that this is a different amount from the medical provider’s bill because your insurance company may negotiate lower rates. This calculation should give you the dollar amount you owe.

Receive a Suitable Coinsurance With Health for California

Whether you’re new to insurance or you’re looking to make a switch, it’s crucial to understand how coinsurance costs work and how to calculate them. If you’re looking for a more convenient coinsurance structure, it might be time to shop around for a suitable health care plan with a reputable provider like Health for California.

At Health for California, we provide a fast, easy and accurate online application process to make getting insured easier. If needed, we’ll guide you through the entire process, from the initial quote and explaining the terms to filling out an application. We also offer free access to licensed agents to answer all your questions about coinsurance, coverage and other cost-sharing requirements. You’re also welcome to enquire about dental and vision insurance plans for more comprehensive coverage.

To get the coverage you need, request a free quote and contact our experienced agents at Health for California today!