What coinsurance means after the deductible

HealthCare.gov defines coinsurance as the percentage of the cost of a covered service you pay after you have paid your deductible. Twenty percent is the glossary’s example, not a Florida average.

The office-visit example

HealthCare.gov uses an allowed amount of $100 for an office visit and 20% coinsurance. If you have already met the deductible, you pay $20 and the plan pays the rest. If you have not met the deductible, you pay the full allowed amount, $100. Those dollars illustrate the rule. They are not a quote for a visit in Sunrise.

The same glossary walks through a larger bill so you can see coinsurance and the out-of-pocket maximum together: an allowed cost of $12,000, a $3,000 deductible, 20% coinsurance, and a $6,850 out-of-pocket maximum. You pay the deductible first, then 20% of what remains, until the maximum stops the total. Read that page for the arithmetic rather than treating any of those figures as your plan.

What people mix up

• Coinsurance is a percentage. A copay is a fixed dollar amount for a service. A plan can use both.
• The percentage applies to the allowed amount, not to whatever a provider first writes on a bill.
• Out-of-network care can be left out of the in-network out-of-pocket maximum. See out-of-pocket maximum.
• In general, lower-premium plans come with higher coinsurance. Confirm it on the summary of benefits.

The deductible has to be met before this percentage usually starts. If that word is the confusing one, start with deductibles.