Coinsurance is a cost-sharing option that lets you split medical bills with your insurance provider, making healthcare expenses more manageable. Along with deductibles and co-pays, This are the out-of-pocket costs you may need to pay for health care services. It’s important to understand these terms and how to calculate them in order to manage your health coverage effectively.

What Is Coinsurance?

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

Breaking Down the 80/20 Coinsurance Model

The 80/20 coinsurance model means your insurance company pays 80% of the total health cost, while you cover the remaining 20%. Insurance providers may offer various structures, such as 30/70 or 40/60, detailed in your plan description.

What Is the Difference Between Coinsurance and Copay?

Coinsurance is a percentage of the total medical bill that you pay, while a copay is a fixed dollar amount you pay at the time of receiving care. For example, you might have a $200 copay for ER visits and a $20 copay for primary care visits.

The main difference between the two is that the coinsurance amount varies, while the copayment remains the same across medical bills. In some cases, a copay might count toward your deductible, while you may only pay coinsurance after you meet the deductible. Your out-of-pocket maximum limits the amount you need to pay for healthcare costs. After reaching this limit, the insurance company may cover all costs for the rest of the policy term.

What Does 0% and 100% Coinsurance Mean for You?

0% coinsurance means your insurance company pays for the entire claim after you’ve met your deductible. Be sure to clarify with your insurance provider if you see 0% on your Summary of Benefits, as it may mean you’re responsible for 100% of the costs.

On the other hand, 100% coinsurance means you’re responsible for the entire medical bill, even after meeting the deductible, until you reach your plan’s annual out-of-pocket maximum.

How to Calculate Coinsurance Costs?

  1. Know Your Rate: Check your Summary of Benefits for your rate and service-specific variations.
  2. Determine Your Deductible: Pay bills in full until reaching your deductible.
  3. In-Network Discounts: Using in-network providers can reduce your total bill. Find theallowed amountin your Explanation of Benefits.
  4. Calculate Your Share

Need Help with Health Insurance?

Skyline Benefit is an independent health insurance broker in Fullerton, CA that offers affordable and flexible health insurance options.  Selecting the best health insurance plans can be overwhelming; our mission is to simplify the process and help our clients every step of the way.

Schedule a consultation today. Call us at: (714) 888-5112

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