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  • Coinsurance is the consumer’s share of the costs of covered benefits
  • Traditionally, coinsurance starts after customers reach their plan deductible
  • Coinsurance counts towards the limit on out-of-pocket costs under Obamacare
  • Coinsurance is lower among high premium policies than low premium plans


Coinsurance is a major part of the true costs of health insurance. Like premiums, it is part of every policy. The high premium policies generally have low coinsurance. Coinsurance can vary with the consumer choice to use network or outside resources. Most plans that permit outside resources require higher rates of coinsurance from members when they use outside sources. Comparison shopping is an important tool for finding the best values in health insurance. One must consider the total costs including deductibles, copays, and coinsurance.

Comparison shopping is an important tool for finding the best values in health insurance. One must consider the total costs including deductibles, copays, and coinsurance. Click here to start comparing health insurance quotes right here for free!

Coinsurance Before and After


Deductibles are the fulcrum of a health plan. It turns the plan from an all-paid by consumer deal into an agreed split of costs between consumer and insurance.

In traditional terms, during the time before reaching the deductible, consumers must pay all of the costs of a benefit or service. However, most policies today offer copays from the start for allowed services and also provide the no added cost prevention services required by Obamacare.

Coinsurance still relates strongly to the deductible, and this has been a source of customer dissatisfaction as plans increase premiums and deductible limits.

Terms Can Be Confusing

The modern use of traditional terms can cause confusion. Insurers seem to redefine terms like copays and coinsurance to suit their products. Without a standard definition, the opposite meanings can through rather than the intended idea. For example, a company introduced a 100 percent coinsurance policy in California. The customers thought it meant they had to pay 100 percent coinsurance after the deductible.

The authors intended the opposite; they meant that insurance would pay all costs after the deductible minimum. Traditionally, the phrase 100 percent coinsurance does mean that the consumer pays all.

The insurer revised its meaning to fit its product, and it confused the public instead. There is no substitute for a careful reading of the plan’s explanation of benefits.

Coinsurance and the Obamacare Plans

The Obamacare Marketplace sell qualified health plans in four types. The types have varying levels of coinsurance. The below-listed items focus on the types of plans and their coinsurance requirements.

  • Platinum plans have the lowest ratio of coinsurance to insurance payments for covered benefits performed by network sources. The approximate cost share is 10percent of the allowed costs of the benefit.
  • Gold plans have high premiums and an 80 percent insurance payment against 20 percent from the consumer. The pattern is that high premiums help authorize lower copays and coinsurance.
  • Silver plans have a wide range of deductibles because some are eligible for Health Savings Accounts. The Health Savings Accounts permit payment of expenses without reaching the deductible threshold. The silver plans divide covered benefit costs at 30 percent from the consumer and 70 percent from the insurance company.
  • Bronze plans have the lowest premiums and the highest rates of copays, deductibles, and coinsurance. The consumer must pay an average of 40 percent of the allowed costs for a covered benefit. The high deductibles are a barrier for some consumers, and they get a small benefit from insurance payments during the annual cycle.

Copays and Coinsurance


Traditionally, there are no coinsurance payments until the insurance company must start paying benefits. The insurance company obligation to pay results from passing the deductible threshold. Coinsurance represents the consumers share of the amount due for the service or benefit. It is part of the price, and the amounts are sometimes substantial.

Copays are small charges that do not reflect the value of the service. Copays are usually flat fees paid at the time the medical services provider performs the service or benefit. Copays do not depend on reaching the deductible. Copays can discourage frivolous use of resources and ensure that there will be enough of the benefit to meet the needs of the entire membership.

Coinsurance and Deductibles

The traditional use of the terms deductible and coinsurance state that consumers must pass the deductible minimum first. Then the insurance pays its share of the benefits, and the customer pays their share. The terms have acquired new usages.

The coinsurance may come before the deductible minimum in some plans, EPO plans, in particular, rely far less on deductibles when offering services. Further, the Obamacare law brought a group of prevention services that require no coinsurance or copays.

Effect of Deductibles on Coinsurance


Coinsurance rises and falls in the opposite direction of the deductible amount. Plans with high deductibles often have low rates of coinsurance. The lowest rates of coinsurance go with the highest premiums too. The coinsurance responds to the level the customer is willing to spend out-of-pocket and for premiums.

Coinsurance is part of the overall balance of a plan. Each plan accepts all and has a design to use insurance funds and consumer funds to cover the allowed costs of covered benefits.

Networks Matter

The types of plans on the Marketplace include HMO, PPO, EPO, FFS, and POS. All of these types of managed care depend on a responsive network of medical providers, doctors, and hospitals. The insurer recruits and signs an adequate number of facilities and professional medical services to cover the expected needs of the plan participants. The below-listed items describe the effects of managed care on coinsurance.

HMO is the health Maintenance Organization. The HMO delivers care through a primary care physician. The primary care doctor treats the client when possible, and in other complicated cases he or she makes referrals to network specialists. This type of plan charges coinsurance on covered in-network benefits. Excepting emergencies, it does not pay for outside resources.

PPO is the preferred provider Organization it shares the costs of in-network at a lower rate of coinsurance than outside sources. Customers can choose when to pay more by going outside the network. Outside spending does not count towards plan limits

EPO is the Exclusive Provider Organization. It features low copays and low rates of coinsurance. The EPO drives consumers with price incentives to use network resources. Those that spend outside the network get no insurance cost sharing from the EPO.

FFFS is the fixed-fee-for-services organization. This style of managed care does not restrict the consumer, and they can spend wherever they wish. The provider tied insurance payments to pricing. The FFFS will only pay the allowed fee for the particular service. Any balance is the responsibility of the customer.

Original Medicare is an excellent example of the FFFS. Medicare card holders can engage any medical professional that accepts Medicare.

POS stands for Point of Service plans. The plans require a primary care physician to ration care. When the primary care physician makes referrals to network resources, the insurance company pays its share of the costs. When the primary care physician refers the customer to an outside resource, then the POS organization pays its share, and the consumer pays only the coinsurance or copay.

Coinsurance and the Network


Coinsurance may apply at much higher rates when consumers use resources that are outside of the Plan’s network. Some plans like the EPO and HMO do not pay anything towards the fees of outside network providers. Between higher coinsurance and low or no insurance coverage, using outside resources is costly for consumers.

A hidden cost arises when one considers that the outside spending does not move the consumer closer to the expense limits.

Obamacare reduces coinsurance

Cost-sharing reduction subsidies can reduce the levels of coinsurance for those with qualifying income. These subsidies also lower the plan limits for expenses. It applies to Silver plans purchased through the Marketplace. Eligibility depends on annual family income. One must earn between 100 percent and 250 percent of the Federal Poverty Level.

Coinsurance and the Total Costs of Care


One must consider coinsurance as a necessary part of the expenses for health coverage. As insurers drive for greater profits, increasing deductibles and coinsurance are among the favorite steps. Coinsurance has two sides. It advances the client to all insurance paid benefits stage; it adds to the out-of-pocket costs.

Estimating coinsurance is not a real possibility. When comparison shopping, one can estimate the levels of usage for each family member. For those with heavy or regular care needs, then a high premium policy is best because they charge lower rates of coinsurance. The Obamacare Silver Plan may be best for this feature, as described below.

  • Those applicants earning less than 250 percent of the Federal poverty level can get costs reduction subsidies.
  • Those earning less than 250 percent of the federal poverty level can get a lower maximum out-of-pocket expenses limit.

Coinsurance may not cover all

Coinsurance covers an allowed amount for a network benefit. If the actual costs of the benefit exceed the allowed amount of the coinsurance, then the consumer will have to pay more. They would owe a balance billing which is their responsibility once the insurance company pays its agreed cost share.

Incurring charges that exceed the allowed amounts is another way that consumers can acquire higher than expected debts; further, these balance billings do not count toward the plan limits for deductibles or out-of-pocket expenses.

Coinsurance is an Important Part of Health Insurance


Coinsurance is usually a set percentage, but many policies vary the coinsurance with the benefit. Unlike copays, the coinsurance represents part of the cost of the covered benefit; it is the consumer’s share of the allowed cost of a service. Comparison shopping can detect the impact of coinsurance. Coinsurance payments begin for covered benefits after the deductible starts the insurance payments for covered benefits.

Coinsurance ends when the consumer reaches the limit for deductibles and out-of-pocket costs. Then the insurer must pay the entire costs of covered benefits.

Comparison shopping helps identify the value of health plans which depend greatly on the amounts of consumer spending needed to use the covered benefits. Scroll down to explore healthcare quotes in your state for free!

[su_spoiler title=”References:” icon=”caret-square” style=”fancy” open=”yes”]

  1. https://www.healthcare.gov/why-coverage-is-important/pay-less-before-meeting-deductible/
  2. https://www.healthcare.gov/why-coverage-is-important/protection-from-high-medical-costs/
  3. https://www.healthcare.gov/glossary/co-payment/
  4. http://obamacarefacts.com/insurance-exchange/health-insurance-plans/
  5. http://obamacarefacts.com/health-insurance-premium-and-cost-sharing-explanation/
  6. https://www.healthcare.gov/choose-a-plan/your-total-costs/
  7. https://www.healthcare.gov/coverage/pre-existing-conditions/
  8. http://obamacarefacts.com/health-insurance-networks/
  9. http://obamacarefacts.com/2016/11/07/epo-and-out-of-network-benefits/
  10. http://obamacarefacts.com/covered-benefits/
  11. http://obamacarefacts.com/insurance-exchange/cost-sharing-reduction-subsidies-csr/
  12. http://obamacarefacts.com/what-is-the-best-health-insurance-plan/
  13. https://www.healthcare.gov/glossary/co-insurance/
  14. https://www.healthcare.gov/glossary/allowed-amount/