Understanding Coinsurance

What is coinsurance?

Coinsurance is a percentage of the cost that you pay. Your plan pays the rest.

You usually pay coinsurance after you meet any deductible. (A deductible is the amount you pay first before your plan starts to help.)

Coinsurance vs. copay

Coinsurance and copays are both your share of the cost. But they work in different ways.

• A copay is a set dollar amount. For example, you pay $10 for a visit.
• Coinsurance is a percentage. For example, you pay 20% of the cost.

With a copay, you always know the exact dollar amount. Under coinsurance, your cost depends on the service’s price.

A simple example

Say a service costs $100, and your coinsurance is 20%.

• You pay $20. (That is 20% of $100.)
• Your plan pays the other $80.

If the service costs more, your share goes up. If it costs less, your share goes down.

Your share is based on the amount your plan agrees to pay. This is often lower than the full price

Where you might see coinsurance

Coinsurance may apply to certain services and drugs. For example, some specialty drugs use coinsurance instead of a copay.

Every plan is different. To see where your plan uses coinsurance and how much, read your plan’s Summary of Benefits.

Good things to know

You have protections:

• You never pay more than your share. A provider in your plan’s network cannot charge you extra. This is called protection from balance billing.
• There is a yearly limit. Most plans set a top limit on what you pay for medical care in a year. Once you reach it, you pay nothing more for covered medical services for the rest of the year.

A note about Medicaid and Extra Help

Many Elderplan members have Medicaid or get Extra Help. If you do, you may pay little or nothing in coinsurance.

In fact, some Elderplan plans have $0 coinsurance and $0 copays for covered care. To see what your plan charges, read your plan’s Summary of Benefits, or contact us.