What Is Coinsurance
Coinsurance is the percentage of covered medical costs you pay after you meet your deductible. If your health plan has 20% coinsurance, the plan pays 80% of covered services and you pay 20%. This cost-sharing continues until you hit your out-of-pocket maximum, which is the total amount you'll pay for covered care in a year.
Coinsurance in Government Benefits Programs
Coinsurance works differently or not at all depending on which government program covers you:
- Medicaid: Most state Medicaid programs charge little to no coinsurance. States must limit cost-sharing for emergency services and certain preventive care under federal rules. Many states waive coinsurance entirely for low-income beneficiaries. Check your state's Medicaid handbook for specifics, as rules vary by state and eligibility category.
- SNAP, TANF, WIC: These programs don't involve coinsurance because they're not health insurance. They provide food, cash assistance, and nutrition services without medical cost-sharing.
- Marketplace plans with subsidies: If you get health insurance through Healthcare.gov with tax credits, your coinsurance percentage depends on the metal level you choose. Bronze plans have higher coinsurance (around 40%), while Silver and Gold plans have lower percentages (25-30%). Platinum plans cap coinsurance at 10%.
How Coinsurance Affects Your Costs
Coinsurance is separate from your deductible and copay. Here's the order of how costs work:
- You pay all costs until you meet your deductible (typically $500 to $1,500 for Marketplace plans).
- Once you meet the deductible, coinsurance kicks in. You pay your percentage, the plan pays theirs.
- Once you reach your out-of-pocket maximum (federally capped at $9,100 for individuals and $18,200 for families in 2024), the plan pays 100% of covered care.
Example: You have a $1,500 deductible and 20% coinsurance. You visit a specialist who charges $500. You pay the full $500 toward your deductible. Later, you have a surgery costing $10,000. Your deductible is now met, so you pay 20% of $10,000 ($2,000) and the plan pays $8,000.
Common Questions
- Does Medicaid have coinsurance? Most Medicaid beneficiaries pay $0 to $5 copays for office visits, with coinsurance waived or capped at minimal amounts. Emergency services cannot have cost-sharing. Contact your state Medicaid office for your specific plan's rules.
- How do I know my coinsurance percentage before picking a plan? Check the Summary of Benefits and Coverage (SBC) document when comparing Marketplace plans. It clearly shows the coinsurance percentage for different types of care like office visits, specialist visits, and hospitalization.
- Can I get help paying my coinsurance costs? If you qualify for Medicaid, it often covers coinsurance owed to Marketplace plans through cost-sharing reduction programs. Nonprofit organizations and state health departments also offer financial assistance for medical bills.