Coinsurance is also known as ‘Rate of Payment’. This is the % that the insurance company will pay AFTER the deductible has been met. Health insurance policies can have different coinsurance percentages so be sure to read your policy docs and ask your agent if you’re unclear. Most common options are: 100%, 80%, and 50%. These can also be shown on your policy as 100/0, 80/20 and 50/50 respectively. The formula for this is: (Ins company percent/Patient percent). You should always verify your percentage of responsibility in your policy documents.
Let’s say your insurance plan has a $2,000 deductible with 80% (80/20) coinsurance with a maximum out of pocket of $2,000 after deductible.
Claims examples:
You break your leg and receive a bill for $8,000 from the hospital. Here is how your charges would be applied:
| Full Charge | $8,000 |
| Deductible | $2,000 |
| Coinsurance | $1,200 |
| Patient Responsibility | $3,200 * |
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*if your plan is a PPO and the provider of treatment is in-network you should be eligible for network discounts before you pay anything out of pocket. This % discount can vary by network and by service but a rule of thumb estimate is about 30%. Here is what the same claim would look like after receiving network discounts:
| Full Charge | $8,000 |
| Charge AFTER network discount | $5,600 |
| Deductible | $2,000 |
| Coinsurance | $720 |
| Patient Responsibility | $2,720 |
