Term Three: Coinsurance Copy

Coinsurance is the percentage of costs YOU pay after you’ve met your deductible. In both HMO and PPO plans, coinsurance usually ranges between 20% and 50%.

How does coinsurance work?

In this example, let’s say that the allowed amount for your plan for an office visit to a specialist doctor is $150, and your coinsurance is 30%, but you must meet your deductible before the coinsurance starts.

Allowed Amount for Service

The “allowed amount” the insurance company negotiated with the doctor is $150. If the doctor charges more for a visit, you are only responsible for the allowed amount.

Deductible NOT Met

If you haven’t met your deductible, you will pay the full allowed amount of $150 and that payment will apply to your deductible.

If Deductible IS Met

If you’ve met your deductible, you pay $45 ($150 x 30%), and the insurance company pays the rest.

NOTE: If no deductible applies to a specialist office visit, you will pay the copay (ranging from $20 to $75) instead of the coinsurance amount.