What is coinsurance?
Learn about coinsurance and how to calculate your costs.
Coinsurance is the amount you pay for covered healthcare after you meet your deductible.
This amount is a percentage of the total cost of care — for example, 20% — and your Blue Cross plan covers the rest.
What is the difference between coinsurance and a copay?
Coinsurance and a copay (copayment) are both ways that you share the cost of healthcare with your insurance plan. Your plan sets the amounts.
- Coinsurance is a percentage of the total cost for healthcare.
- 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.
Learn more
Find out how coinsurance works with other healthcare costs and learn how and who to pay for healthcare.
Calculate costs
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 service.
This amount is a discounted cost that doctors in your plan network agree to charge.
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.
This is general information about how plan benefits work. Review the Summary of Benefits and Coverage and your specific health plan benefit booklet for information about how your plan works.
*It’s up to you to always check if your provider is in your health plan network before you receive services. Not all providers are in every network. You may pay more or for all of your healthcare costs if your provider is out of your network or does not have a contract with Blue Cross (this is called a non-participating provider). You can verify if your provider is in your network by calling customer service at the number on the back of your member ID card.