“What is coinsurance?” In simple terms, coinsurance is the percentage of healthcare costs that you, the policyholder, are responsible for paying after you’ve met your deductible.
Let’s illustrate this with an example. Suppose you have a health insurance plan with a deductible of $1,000 and a coinsurance rate of 20%. If you undergo a medical procedure that costs $4,000, you will first pay the $1,000 deductible. After that, your insurance will cover 80% of the remaining $3,000, leaving you responsible for the remaining 20% (which amounts to $600). The insurance company pays $2,400, and you pay $600.
The Importance of Meeting Your Deductible
Before coinsurance kicks in, you must meet your deductible for the year. This is the amount you need to pay out of your pocket before your insurance begins to contribute. Once you’ve reached your deductible, coinsurance comes into play, lightening the financial burden on your shoulders for the rest of the policy year.
Out-of-Pocket Maximum: Your Safety Net
It’s essential to be aware that there’s a limit to how much you’ll have to pay in coinsurance and deductibles combined. This limit is called the “out-of-pocket maximum.” Once you reach this limit during the policy year, your insurance company will cover 100% of your covered medical expenses. This is a significant safety net, ensuring that you won’t face overwhelming medical bills even in the case of severe health issues.
Coinsurance vs. Copay: What’s the Difference?
Coinsurance is often confused with copay, but they are different cost-sharing methods. A coinsurance is a percentage of the cost you pay for covered services. A copay is a fixed amount you pay for a specific service. A visit to your primary care doctor might come with a $30 copay, while coinsurance. There might be a percentage payment for services like hospital stays or surgeries.
How do I know what I should pay?
When an insurance company received a bill from a doctor’s office or hospital, they process it and determine if there is any remaining patient responsibility. They respond with a report called an explanation of benefits, or EOB, An EOB breaks down the fees allowed, their payment responsibility and yours. This information is then made available to both the health care provider and the patient. You can contact your insurance company for an explanation of benefits if they do not send it to you automatically.
Choosing the Right Plan for You
When selecting a health insurance plan, it’s crucial to consider your health needs, budget, and risk tolerance. Plans with lower monthly premiums might have higher coinsurance rates, while those with higher premiums might come with lower coinsurance. Understanding these trade-offs will help you find the right balance that suits your unique situation.
Coinsurance is a part of the cost-sharing obligations of a health insurance plan. By grasping the concept of coinsurance and how it relates to deductibles and out-of-pocket maximums, you’ll be better equipped to navigate what resources you need to finance healthcare expenses
ABOUT THE AUTHOR
Dr. Dina Strachan
Harvard and Yale educated board certified dermatologist