What Is Coinsurance In Health Insurance?

Coinsurance in health insurance is an aspect of health insurance that may seem grey to a lot of persons and is what this article is set to clarify. Before we get into the subject of coinsurance, let’s take a quick look at the root subject which is health insurance.

Table of contents

What Is Health Insurance?

Health insurance is an insurance contract that requires an insurer to pay a part or all of a person’s healthcare costs in exchange for a premium. To further explain, health insurance typically pays for the medical, surgical, prescription drug, and sometimes dental expenses of the insured.

Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly.

It is often included in employer benefit packages as a means of enticing quality employees, with premiums (the amount of money that an individual or a business pays to the insurance provider periodically) partially covered by the employer but often also deducted from employee paychecks.

The cost of health insurance premiums is deductible to the payer, and the benefits received are tax-free, with certain exceptions for some corporation employees.

How Does Health Insurance Work?

Health insurance can be tricky to maneuver. Managed care insurance plans require policyholders to receive care from a network of designated healthcare providers for the highest level of coverage.

If patients seek care outside the network, they must pay a higher percentage of the cost. In some cases, the insurance company may even refuse payment outright for services obtained out of network.

Many managed care plans require patients to choose a primary care physician who oversees the patient’s care, makes recommendations about treatment, and provides referrals for medical specialists.

Insurance companies may also deny coverage for certain services that were obtained without preauthorization. In addition, insurers may refuse payment for name-brand drugs if a generic version or comparable medication is available at a lower cost.

All these rules should be stated in the material provided by the insurance company and should be carefully reviewed. It’s worth checking with employers or the company directly before incurring a major expense.

Increasingly, health insurance plans also have copays, deductibles, and coinsurance. Insurance plans with higher out-of-pocket costs generally have smaller monthly premiums than plans with low deductibles.

When shopping for plans, individuals must weigh the benefits of lower monthly costs against the potential risk of large out-of-pocket-expense in the case of a major illness or accident.

If you’re self-employed, you may be able to deduct up to 100% of the health insurance premiums you pay out of pocket.

SEE ALSO: Best Health Insurance For College Students

What Are The Available Health Insurance Plans?

There are four health insurance plans you should know. The plan type that is best for you depends on what you or your employees want, as well as how much you’re willing to spend. Here’s a summary of each type of health insurance plan.

#1. Preferred Provider Organisation (PPO) Plans

The most common health plan is the preferred provider organization (PPO) plan. Employees covered under a PPO plan need to get their medical care from doctors or hospitals on their insurance company’s list of preferred providers in order to get their claims paid on the highest level.

#2. Health Maintenance Organisation (HMO) Plans

The next plan is the health maintenance organization (HMO) plan. These plans offer a wide range of healthcare services through a network of providers that sign up exclusively with the HMO, or who agree to provide services to members.

Employees participating in HMO plans will need to select a primary care physician to provide most of their healthcare and refer them to an HMO specialist as required.

#3. Health Savings Account (HSA) Qualified Plans

There is the Health Savings Account qualified plan. These plans are like the preferred provider organization plans(PPO) designed specifically for use with health savings accounts (HSAs).

An HSA is a special bank account that allows users and participants to save pre-tax money to be used particularly specifically for medical expenses in the future. HSAs can be used alongside health reimbursement arrangements (HRAs), depending on the HRA offered.

#4. Indemnity Plans

The last plan open for consideration is the Indemnity plan. This plan allows members to direct their own healthcare and generally visit any doctor or hospital of their choosing.

The insurance company then pays a decided set portion of the total charges. Employees may be required to pay for some services upfront and then apply to the insurance company for reimbursement.

What Is Coinsurance?

Coinsurance is simply the percentage of costs of a covered health care service you pay after you’ve paid your deductible. It does not begin until after the insured has met their deductible.

This means you’ll pay all of your medical costs until reaching your deductible. Afterward, you will only pay a percentage of the costs while the insurance company takes care of the rest.

How Does Coinsurance Work?

Here is a typical example of how coinsurance works; say the following amounts apply to your plan and you need treatment for a demanding health condition. 

  • Allowable costs are $10,000
  • Deductible: $3,000
  • Coinsurance: 20%
  • Out-of-pocket maximum: $5,650

You’d pay all of the first $3,000 (your deductible).

Then pay 20% of the remaining $7,000 which is $1,400, your coinsurance.

The sum of your out-of-pocket costs would be $4,400 which is your $3,000 deductible plus your $1,400 coinsurance.

If your total out-of-pocket costs get to $6,850, you will only pay that amount, including your deductible and coinsurance while the insurance company would pay for all covered services for the rest of your plan year.

What Are Deductibles? 

A deductible is a set amount of money that one must first pay before their insurance company begins to do its part. For example, if your policy comes with a $1,000 deductible, you would pay the first $1,000 of your healthcare expenses during the policy year.

Many health insurance plans cover routine services and even prescription drugs. As a matter of fact, the Affordable Care Act mandates that preventive care, like yearly diagnoses such as mammograms, and immunizations, does not require payment toward a copay, coinsurance, or deductible.

High-deductible plans often come with lower monthly premiums, which means you’ll pay less each month for your plan but will have to pay more out of pocket before your plan starts to offset what is left of the bill.

If you have a low A deductible plan, then it means higher costs for the monthly premium, but because you’ll reach your deductible more quickly, your insurance will begin covering expenses sooner.

What Is Out-Of-Pocket-Maximum?

An out-of-pocket maximum is simply the medical expense you must pay for yourself during a policy year. Once you have reached your out-of-pocket maximum, the insurance company bears the brunt of any costs for the rest of the year. Deductibles, coinsurance, and copays all contribute to your out-of-pocket maximum.

What Are Copays?

The word copay has appeared in this article a number of times and at this point, it is safe to ask what coinsurance is?

A copay is a fixed amount you pay for a health care service, usually after you have received the service. The amount varies depending on the type of service rendered.

Your health plan will determine your copay for different types of services, and when you have one. You may have a copay before you’ve finished paying your deductible or afterward. You can also have a copay while you owe your coinsurance.

What Is The Difference Between Copays And Coinsurance?

Both coinsurance and coinsurance refer to a person’s responsibility for a part of their healthcare costs.

The most significant difference between copays and coinsurance is that coinsurance is a set amount that the patient must pay for a specific treatment while  Coinsurance is a percentage of the total cost of health care.

For example, a very common coinsurance arrangement is that the medical insurance company pays 80 percent of costs for a given therapy, with the patient paying 20 percent. Copayments and coinsurance, along with deductibles, are examples of cost-sharing.

Can Coinsurance Rates Be Lowered?

The answer to this question is yes! However, rates can be lowered. There are Cost Sharing Reduction (CSR) subsidies available to health insurance customers that purchased a silver-level plan through the public marketplace, who meet the criteria for a premium tax credit, and who earn between 100% and 250% of the Federal Poverty Level.

These subsidies reduce coinsurance, copays, deductibles, and out-of-pocket maximums by increasing the actuarial value of the plan.

Actuarial value is a way of measuring the overall value of a plan to the customer. The higher the actuarial value, the more benevolent the plan.

There are plans that offer 100% after deductible, which automatically means 0% coinsurance. What this implies is that once your deductible is reached, your insurance provider will pay for 100% of your medical costs without requiring any coinsurance payment.

FAQs on Coinsurance In Health Insurance?

What does Health Insurance by Digit comes with?

Health Insurance by Digit comes with 0% Copays.

Are Coinsurance clauses added to insurance policies?

Coinsurance clauses are mostly added to insurance policies alongside deductibles.

Does the copay amount vary for different services?

Yes, the copay amount varies for different services but the sum of money remains fixed.

Are Health insurance policies with copay clauses cheaper?

Health insurance policies with copay clauses are comparatively cheaper than those without.


Coinsurance in health insurance is the percentage of costs you pay after you’ve met your deductible while copay is a set rate you pay for prescriptions, doctor visits, and other types of care. A deductible is the set amount you pay for medical services and prescriptions before your coinsurance begins to read.

Out-of-pocket expenses are the medical expenses you must pay from your own pocket. The lower your monthly premiums, the more out-of-pocket expenses you will have to pay before the insurance begins to cover your bills.



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