Learn more about coinsurance and how to calculate your costs below. To understand how coinsurance works with other health care costs, see paying for health care.
What is the difference between coinsurance and a copay?
Coinsurance and copay (copayment) are both ways that you share the cost of health care with your insurance plan. Your plan sets the amounts. Coinsurance is a percentage of the total cost for health care. A copay is a small, flat fee you pay at the time of service. Not all plans have copays, but many plans have coinsurance.
When do I pay coinsurance?
You begin to pay coinsurance after you reach your deductible. Your plan tracks how much you pay toward your deductible. This information is on the Explanation of Benefits (EOB) your health plan sends after you receive care. The EOB shows how much coinsurance, if any, you must pay. You pay this amount directly to the doctor’s office, hospital or pharmacy.
How do I calculate my coinsurance costs?
How much you need to pay depends on the “allowed amount” that a doctor can bill for a health care service. This amount is a discounted cost that doctors in your plan network agree to charge.
Here’s an example of how coinsurance costs work:
John’s health plan has 80/20 coinsurance. This means that after John has met his deductible, his plan pays 80% of covered costs, and John pays 20%.
| The allowed amount for a doctor visit: | $100 |
| The health plan pays 80% coinsurance: | $80 |
| John pays 20% coinsurance: | $20 |
Before his visit, John checked to make sure his doctor was in the plan network* so he could get the most coverage and pay less out of his own pocket. If John visits a provider outside his plan network, he may pay more.
More about health care costs
How do I track and see my claims?
What is a network and why does it matter?
7 ways to save on health care
Why you might need prior authorization
When does a preventive visit turn into an office visit?