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Coinsurance After Deductible - How To Choose Between 100% And 0%

Edward Neeman | Published: September 19, 2018

Calculating coinsurance after deductible

Health insurance, as with any other type of insurance, can sometimes be difficult to understand. From copays to out-of-pocket maximums, no two plans are the same.

Coinsurance is the portion of your medical bill that you are responsible to pay before or after a deductible is met. The portion you pay is based on a percentage and not a dollar amount or fixed price. In this article, we will focus on charges after the deductible.

What Is Your Coinsurance After Deductible?

The amount of money you pay after the deductible that you pay is based on the type of insurance you purchase. If you purchase coverage through the marketplace, you’ll choose from tiered metal levels. They are Bronze, Silver, Gold and sometimes Platinum. Each level of insurance dictates how much your coinsurance will be. If you are on a bronze plan, you will pay 40% of your bill. Silver level customers pay about 30% but this can vary if you qualify for cost-sharing reductions through the affordable care act. Gold customers pay 20% and platinum customers pay 10% of the bill.

If you opt to find health insurance outside the marketplace, then your coinsurance after deductible will be dependent on the plan you choose. Different companies will offer different benefits, so make sure to go through your plan details thoroughly so you don’t get caught off guard when your bill comes.

How to Calculate my coinsurance

The calculation of your coinsurance will be based on the bill for services rendered. If you have a $7,000 bill, then you will pay $2,800 based on a Bronze Plan where you pay 40% and the insurance company will pay the other 60%. It is important to remember that not every service you want is necessarily covered. Always check with your insurer before having any treatment.

Example Of How It Works

You might have a plan where you have an out-of-pocket maximum of $6,000. An out-of-pocket maximum is the most you are required to pay for services considered essential by the insurance company. Say you have met your $250 deduction, then you break your leg on a ski trip. You arrive at the hospital and are treated then you receive a bill.

Hospitals don’t usually ask for the payment beforehand on coinsurance as they have not calculated the total cost yet. Once all calculations are added, the hospital gives you a bill or expects payment on the spot. The cost will be calculated on the services performed and what was covered. So even though you may only be responsible for 40% of the bill, you may be charged more than that due to your insurance not covering the service at the time of your accident.

What 100% Coinsurance After Deductible Means

Having 100% coinsurance is anyone dream. After you have met your yearly deductible certain services are covered at 100%% and this means that you do not pay one penny towards the treatment. Your insurance company covers the entire bill so long as it is an agreed upon service that is considered essential by the insurer. There may be some charges on coinsurance after deductible, but your plan brochure will outline any and all possible charges.

Do You Pay Coinsurance After Deductible and Out-of-Pocket Maximum?

After you have met your out-of-pocket maximum there maybe somethings you have to pay for, but they are usually services that are deemed non-essential or non-medically necessary. Once you have met the maximum out-of-pocket cost, speak to your insurance company and make sure you are aware of the rules and your rights before you proceed with any other treatment.

It is important to note that the out-of-pocket maximum applies only to the calendar year only. Meaning if you start insurance in may, and meet your out-of-pocket max in July, then you will have services covered at 100% coinsurance until December 31st of that year.

Insurance is a minefield full of hidden costs and sometimes confusing payment structures. Having little to no costs out of your own pocket is the ideal when it comes to insurance, but this is not always to your favor. Most people prefer a copayment, which is a straight up dollar amount that you pay, it is less of a headache to work out, and you know what you will pay before you have a procedure.

If you want the most bang for your buck, the buy a plan that has low costs on everything and if it has 100% coinsurance, then that would be your best bet for maximum savings on your health insurance.