Health Insurance Coverage Explained

A coinsurance occurs when there is cost-sharing between the insurance company and the covered member/family.  The insurance company may tell you that your responsibility is a 20% co-insurance and that they will cover the rest of the charges (remaining 80%).  Quite often a coinsurance comes in to play after an individual or family deductible has been reached.

Example: Your opthamologist visit is $400 and Optima informs you that you have a 20% coinsurance after meeting your $200 deductible.  Currently, you have met $0 of your deductible. Your responsibility would be: $200 of the deductible and then 20% of the remaining $200 specialist visit charge = $40.00. The total you can expect to pay for the visit is around $240.

This can vary visit to visit depending on the types of services and procedures your healthcare provider performs (even when it may seem routine to you).

A copay is a set fee that you are responsible for each time you visit a doctor.  There are usually tiers or copays where a primary care doctor is typically less than the copay you may have for a specialist. Some plans have a copay due in addition to a co-insurance.

The set amount an individual or family must reach before transferring over to coinsurance coverage for medical services.  Some plans have relatively low individual and family deductibles of $200 – $500 while other plans have larger $5000 – $9500 deductibles.  Once you have met your deductible you may only be responsible for a fraction of the percentage of your medical care, referred to as a co-insurance.  However, even if you have a deductible, your insurance company has likely provided you with a negotiated discount on services. In-network providers have agreed to discounted rates (although these are different for every insurance company). 

This is the absolute maximum a covered member or family will pay out of pocket for medical care including copays, deductibles, and co-insurance for a defined period of coverage (usually a calendar or a contract year)