What Is Coinsurance?

Definition

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

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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.

How Coinsurance Works

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.

Besides your monthly premium, health insurance has three additional costs: deductibles, copayments, and coinsurance. 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.

Note

The deductible is the amount you must pay out of pocket every plan year before your health insurance kicks in. A copayment is a fixed dollar amount you must pay for health care services after you’ve paid your deductible, such as a $25 copay per doctor visit.

Coinsurance only applies once you've paid your deductible. Once you've met your deductible for the year, your coinsurance percentage will be charged to you, along with any copays that apply.

Coinsurance will continue to be charged throughout the year unless you've hit your out-of-pocket maximum. Once you reach your out-of-pocket maximum, you won't be charged any costs for health insurance aside from premiums, out-of-network services, and any other costs that your plan doesn't typically cover.

Example of Coinsurance

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.

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

Note

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

Health Insurance Marketplace 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 the costs. Although these plans feature low deductibles and out-of-pocket costs, they have higher monthly premiums than bronze or silver plans.
  • Platinum: These plans pay 90% of your health care costs and you pay 10%. They offer very low deductibles but have the highest monthly premiums.

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.

Frequently Asked Questions (FAQs)

What is Medicare coinsurance?

Medicare Part A's coinsurance varies. For example, durable medical equipment comes with a 20% coinsurance, while Medicare-approved inpatient respite care comes with a 5% coinsurance. Medicare Part B's coinsurance is typically 20%. Medicare Advantage, Part D, and Medigap coinsurance amounts vary by plan.

What is the difference between deductible and coinsurance?

Your deductible is your out-of-pocket cost before your health insurance begins to cover costs. After you've reached your deductible, your coinsurance kicks in, and that becomes the amount you're expected to pay out-of-pocket.

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Sources
The Balance uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. HealthCare.gov. “Deductible.”

  2. HealthCare.gov. "Out-of-Pocket Maximum/Limit."

  3. HealthCare.gov. “Coinsurance.”

  4. HealthCare.gov. “The Health Plan Categories: Bronze, Silver, Gold & Platinum.”

  5. Medicare.gov. "Costs."

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