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© TheStreet What is Coinsurance and How Is it Different From Copay?

For such an important part of the average American's life, health insurance can get incredibly, frustratingly complicated. Rather than simply having the comfort of knowing you are covered for your medical needs, you're expected to understand a variety of terms in order to know what's covered, how much you're covered for and what you'll have to pay for.

One such term is coinsurance, a vague term without any added context. But coinsurance involves both you and your insurance provider, and so it's important to understand what it is and how it functions in the insurance process. Should you require a medical procedure, knowing your coinsurance can help you get a better approximation of how much you'll have to pay, and where to go from there.

So what is coinsurance, and what separates it from other figures in your health insurance?

What Is Coinsurance?

Coinsurance is the amount you will pay for a medical cost your health insurance covers after your deductible has been met.

Your deductible, if you weren't aware, is the amount you have to pay before insurance kicks in to help pay. In health insurance, your deductible can get spread to multiple costs or one single cost until it runs out. Once you've reached your deductible, that's when insurance comes in. But in healthcare, you also have the coinsurance to deal with.

Copay or Co-payment refers to a fixed amount of money you need to pay for certain types of treatment when the rest balance amount will be paid to the insurer. The can be a pre-decided amount or a percentage of the total cost of treatment depending on the policy you choose. No, copays do not count toward the deductible. However, copays do count toward the annual out-of-pocket maximum, which is the total amount you are liable to pay for all your healthcare costs in any given year — including copay and coinsurance. This video explains deductibles, coinsurance and copay. A copayment is a specific dollar amount you are usually asked to pay at the time you receive healthcare services. An office visit to the family doctor will have a copay. A coinsurance is a percentage of the allowed charges. Coinsurance is almost always much higher than a copay.

Coinsurance The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%. If you've paid your deductible: You pay 20% of $100, or $20.

Coinsurance is measured as a percentage of what you will pay of the remaining costs compared to what insurance will. Perhaps the most common percentages here are 80/20 - that is to say, your provider will pay 80% of it, and you will pay 20%. Another common set up is 70/30 (you pay 30%).

Coinsurance comes into play when your deductible runs out, and depending on your deductible and your medical history, that amount of time could fluctuate wildly. Someone with a history of medical issues may choose a lower deductible plan (though these tend to have higher premiums) because they anticipate future costs, while someone without a troubling history may be more willing to enroll in a high deductible health plan to avoid high premiums, under the assumption that it is unlikely something major will come up.

Does Your Coinsurance Affect Out-of-Pocket Maximums?

Knowing your deductible is crucial for your health insurance, but once you've reached the end of your deductible you should know your out-of-pocket maximum. That is the maximum amount of overall money you have to pay before your insurance company covers all of the costs.

The money you are personally paying when coinsurance gets factored in does, in fact, go toward your out-of-pocket maximum. So let's say you have a deductible of $1,500 and an out-of-pocket maximum of $5,000. You reach that deductible, and the remaining medical costs you owe lead to $300 out of your own pocket due to coinsurance. Combined, this would mean you've paid $1,800 of your $5,000 out-of-pocket maximum.

So while coinsurance can be a bit of a nuisance, more money you have to take from your own pocket put toward medical costs, it is supposed to have a beneficial purpose of bringing you closer to your maximum. How much your out-of-pocket maximum will be will depend on the sort of insurance plan you end up enrolling in.

Example of Coinsurance

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Let's bring a few figures in to provide a real-life example. Let's say that your healthcare plan has a deductible of $1,000, and you have an 80/20 coinsurance clause.

With this information, say you incur $2,500 in medical costs. You haven't had to use your deductible prior to this, so all $1,000 of it goes toward this cost. From there, we're left with $1,500. How much of this will you be paying via the coinsurance clause?

$1,500 x 20% = 1,500 x 0.2 = $300

Your coinsurance payment here would be $300. Combined with your deductible, that means you would be paying $1,300 to the insurance company's $1,200.

This is why understanding your coinsurance clause is crucial. You're paying much less than you would without insurance, but in this example you still had to pay for more than half of the costs.

If you end up with other medical costs that your insurance covers, though, your deductible is no longer a factor and you would just have to pay the 20% via your coinsurance clause. So if your next medical costs that year are $1,200, you'd only pay $240 of it.

These, however, may be minor examples compared to what medical expenses you may have to deal with. You still have to reach your out-of-pocket maximum before your insurance company starts to cover 100% of the costs. Generally, your out-of-pocket maximum correlates inversely with your premiums. Much like with deductibles, those with higher premiums have lower maximums and those with lower premiums will likely have higher ones.

Coinsurance vs. Copay

Coinsurance and copay, as similar-sounding terms for your healthcare, may be a little confusing. Though they share similarities, they're ultimately different plans for your insurance.

Whereas coinsurance is the percentage you pay for medical costs after your deductible, your copay is a set amount you have to pay for other covered expenses. For example, a prescription medicine can have a copay, as can a physical or other visit to your primary care physician (PCP). Where a coinsurance plan might have you pay 20% for this doctor's visit, a plan with a copay may instead require you to pay a flat fee of $20 while they pay for the rest of it. Depending on the specific figures involved in your specific plan, a copay could be more or less than what the coinsurance is for any given medical cost.

That said, in other ways coinsurance and copay plans are quite similar. Generally copayments, like coinsurance, do not go toward your deductible but do go toward your out-of-pocket maximum.

Coinsurance in Other Insurance Industries

Coinsurance is most prevalent in the health insurance industry. But coinsurance is a way for insurance companies to try and mitigate risk in the event that expenses add up more than they anticipated, so it's not uncommon for you to find coinsurance in other insurance industries as well.

For example, you may find a coinsurance clause when dealing with property insurance. In this industry, the coinsurance dictates that the property must be insured for a percentage of its value. This is particularly common in commercial property.

Much like in health insurance, 80% coinsurance is the most common percentage. That meant if you had a $500,000 property, you would need to insure it for, at the very least, $400,000.

Let's say, though, that you didn't do that. You decided to only insure it for $300,000 in an attempt to save money on the deal. This could lead to a costly coinsurance penalty if something goes wrong.

You should have insured it for $400,000 but only went as far as $300,000 to insure your property (and you have a deductible of $2,000). Now let's say a pipe bursts in the building, causing excessive damage that totals up to $200,000. Your insurance will, when reviewing the case, notice you did not get the amount of insurance the coinsurance clause required and will impose a penalty.

To figure out the penalty, your insurance will divide the amount of insurance you got by how much you were supposed to (in this case, 300,000/400,000 or 0.75) and multiply that by your damage. 200,000 x .75 = $150,000, which is how much your insurance will pay. Thus, here your coinsurance penalty is a whopping $50,000.

There are a number of words and terms related to the way Medicare works, and one of the most important ones to know is coinsurance.

What is Medicare coinsurance?

Coinsurance is the percentage of a medical bill that you (the Medicare beneficiary) may be responsible for paying after reaching your deductible. Coinsurance is a form of cost-sharing; it's a way for the cost of care to be split between you and your provider.

The deductible is the amount you are required to pay in a given year or benefit period before Medicare begins paying its share.

How does Medicare coinsurance work?

Let’s use an example to explain it more clearly.

John has Original Medicare (Part A and Part B) and goes to the doctor for outpatient treatment.

John’s doctor appointment is covered by Medicare Part B, and his doctor bills Medicare for $300. Part B carries an annual deductible of $203 (in 2021), so John is responsible for the first $203 worth of Part B-covered services for the year.

After reaching his Part B deductible, the remaining $97 of his bill is covered in part by Medicare, though John will be required to pay a coinsurance cost.

Medicare Part B requires beneficiaries to pay a 20 percent coinsurance payment after reaching their deductible. This means that John will pay 20 percent of the remaining $97 of his bill, and Medicare Part B will cover 80 percent.

The total amount that John will have to pay for his appointment is $222.40, broken down as follows:

How much is Medicare coinsurance?

Medicare coinsurance is typically 20 percent of the Medicare-approved amount for goods or services covered by Medicare Part B.

So once you have met your Part B deductible for the year, you will then typically be responsible for 20 percent of the remaining cost for covered services and items.

Private Medicare plans, such as Medicare Advantage and Medicare Part D Prescription Drug Plans (PDP), may feature coinsurance of their own.

While 20 percent is the typical coinsurance amount for Medicare Advantage plans, some plans may feature a 70-30 or 90-10 split.

Medicare Prescription Drug Plans may feature coinsurance or copay amounts that vary depending on the type of drug and what tier that drug is in, according to your Medicare drug plan formulary.

Why does Medicare charge coinsurance?

Cost-sharing measures such as coinsurance (and copays, which you can read more about below) are a way to help keep beneficiaries accountable for their care costs.

With no coinsurance in place, a patient could potentially visit a doctor more frequently for unnecessary health care services after they meet their deductible, because they would pay nothing out-of-pocket for the services.

This would leave the insurance plan carrier to cover all costs of such unnecessary care, which would drive up plan costs for other beneficiaries and contribute to overburdening the health care system.

Cost-sharing is one way of helping ensure that patients are more selective about the type of care they seek.

Coinsurance vs. copays

Copayment, or copay, is another term you’ll see used in relation to Medicare cost-sharing. A copay is like coinsurance, except for one difference: While coinsurance typically involves a percentage of the total medical bill, a copayment is generally a flat fee.

For example, Part B of Medicare uses coinsurance, which is 20 percent in most cases. But Medicare Part A uses copayments for hospital stays, which begin at $371 per day for days 61-90 of an inpatient hospital stay in 2021.

The primary difference between coinsurance vs. copays is that copayments are a flat fee amount instead of a percentage.

Get coverage for Medicare coinsurance

One way you can get some coverage for Medicare coinsurance is by purchasing Medicare Supplement Insurance.

Medicare Supplement Insurance plans (also called Medigap) are optional plans sold by private insurers that offer some coverage for certain out-of-pocket Medicare costs, such as coinsurance, copayments and deductibles.

In exchange for paying a monthly premium to belong to the plan, a Medigap plan can help cover the cost of your Medicare coinsurance and/or your deductibles.

If John from our above example had a Medigap plan that covered his Part B deductible and coinsurance, he may have owed nothing for his doctor’s appointment.

Medicare Advantage plans typically include coinsurance

Many Medicare beneficiaries choose to get their benefits through a privately-sold Medicare Advantage plan (Medicare Part C), which provides the benefits of Original Medicare combined into one plan.

Many Medicare Advantage plans may also offer prescription drug coverage, as well as coverage for hearing, dental and vision care, which are not typically covered by Original Medicare.

While a Medicare Advantage plan will likely include coinsurance costs, a plan could help you save on some of your other out-of-pocket health care costs, which could help offset some of your coinsurance payments.

How Do Deductibles And Coinsurance Work

To learn more about Medicare Advantage and to compare the plan options available in your area, call to speak with a licensed insurance agent today.

Copay Coinsurance Deductible

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Copay Coinsurance Deductible Defined

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