Chelsey Tucker graduated with a Bachelor of History degree from Metropolitan State University in 2019. She now writes about insurance with her specialty being life insurance and has been quoted on Help Smart Phone and MEL Magazine.

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Dan Walker graduated with a BS in Administrative Management in 2005 and has been working in his family’s insurance agency, FCI Agency, for 15 years. He is licensed as an agent to write property and casualty insurance, including home, auto, umbrella, and dwelling fire insurance. He’s also been featured on sites like

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Reviewed by Daniel Walker
Licensed Auto Insurance Agent

UPDATED: Mar 19, 2020

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The lowdown...

  • Co-insurance is the consumer’s part of cost sharing for covered benefits
  • Co-insurance can be a substantial for frequent users of covered services
  • Co-insurance traditionally occurs after payment of the deductible
  • Current policies often charge copays and coinsurance from the beginning of coverage

The co-insurance share of insurance costs can be the largest expense in having health insurance. Depending on the amount and type of medical services that the beneficiary uses. The plan determines the percentage of covered benefits that insurance pays.

The pattern and frequency of usage is a factor in the number of copays and co-insurance payments the consumer must make. Comparison shopping is a tool for finding value in insurance plans. One can comparison shop to determine the best match for health care needs and preferences.

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The Out-of-Pocket Maximum

All qualified insurance policies have an out of pocket maximum. Once consumers pay this amount, the insurance must pay all of the costs of covered benefits. The out-of-pocket limit is an important safeguard against costs that could bankrupt nearly everyone. Out-of-pocket expenses include the below-listed types of spending.

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Outside Network Expenses and Benefits Not Covered


Plans may charge co-insurance for any benefit, but the amount paid by the consumer will not count towards the maximums unless it is for a necessary medical benefit. Most plans do not credit cosmetic and purely optional benefits towards the plan maximums or limits. These non-essential benefits are rarely covered when consumers use resources outside of the provider’s network.

Co-insurance is the consumer’s share of the cost sharing called for in the insurance agreement. It is usually a percentage that applies to most services. Often, there are some benefits that charge slightly more or less. Co-insurance rates can change with repetitive use of a benefit, and the amount of co-insurance can go up.

Copayments are usually small amounts of the actual cost of a covered benefit. The insurer uses these to help spread the benefit among all of the users rather than have it used too much by a few users. The copay has the effect of reducing insurer’s costs and adding to profits too.

A copayment differs from coinsurance by the amount; it is usually a small fixed fee such as a $20 copay for every office visit. For many consumers, these small payments add up due to the need to use the benefit frequently.

”Deductible expense” is a phrase that depends on the plan for its meaning. Deductible expenses are every kind of spending that the consumer does to get a benefit covered by the health insurance.

The plans can and do exclude some things from the definition and usually the exclusion makes it harder to reach the deductible amount. For example, a plan may exclude copays from its count of deductible expenses. Many plans provide services to members with a small copay before the deductible has been paid.

In-Network Expenses

Plan providers want their members to use in-network resources. Some plans require this and do not pay at all for the use of outside resources. Among the plans that do pay some level of cost-sharing for outside resources, few credit that spending towards the policy limits.

The Obamacare limit on out-of-pocket expenses includes coinsurance. It only includes covered benefits and for in-network resources. Plans can exclude consumer spending done outside of the network. The out-of-pocket limit in effect has no limit when consumers choose the freedom to use outside resources.

Four Types of Insurance


When selecting a health policy on the Obamacare Marketplace, one must look beyond the premium and consider the costs of copayments and co-insurance on the total costs. After one pays the deductible, there will likely be a copay and coinsurance on every service.

Platinum plans have the highest premiums, and they pay the highest level of benefits. These plans divide costs on an average of 90 percent insurance paid to 10 percent from the consumer.

Platinum plans have the lowest deductibles of any type of Marketplace plan. These high-content plans offer fewer copays and lower co-insurance than the other tiers of plans do.

Gold plans have high premiums and high levels of insurance coverage of benefits. These plans pay about 800 percent of the costs and leave 20 percent for the consumer. Gold plans have small copays and moderate co-insurance demands.

Silver plans provide about 70 percent insurance-paid benefits and leave 30 percent for the consumer’s account. Silver plans have moderately high deductibles.

Some silver plans match with Health Savings Accounts. These High Deductible Health Plans have special limits that work with tax-advantaged savings. The consumer can pay out-of-pocket costs and other fees with funds from the savings account.

Bronze plans have the lowest premiums and the highest deductibles. They charge copays frequently and high levels of coinsurance.

The costs sharing rate is 60 percent insurance paid to 40 percent from the consumer. Plans that require payment of the deductible before any insurance paid benefits are unlikely to pay since the deductibles are very high.

These plans work best for those with few needs beyond annual exams and the free prevention and wellness features. Bronze plans charge copays and coinsurance for benefits that users can get before they pay the deductible.

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Coinsurance in Medicare


Co-insurance is a major expense for Medicare subscribers. After paying the deductibles for Parts A and B, the Original Medicare system leaves coinsurance for subscriber payment.

Part A Hospital Insurance requires co-insurance after payment of a $1,316.00 deductible. There is a zero co-insurance for up to 60 days of hospitalization. After that, Part A charges $329.00 per days for days 61-90, and $658 per day for days 91 and beyond. Once one uses all days within a year and the lifetime limit, the coinsurance is 100 percent of the fees.

Part B leaves a 20 percent co-insurance for subscribers. They will pay an average of 20 percent of the costs of services after paying the Part B deductible. For the calendar year 2017, the Part B deductible is $183.00.

Part C co-insurance varies with the terms of each Medicare Advantage Plan.

Co-insurance is a Major Factor in Insurance Costs


Co-insurance is an important part of the consumer’s share of the costs of health insurance. It is important to find whether the plan counts coinsurance toward out of pocket limits and whether it treats outside resources differently than network sources.

Co-insurance in Medicare is a substantial part of the fees that one must pay for services on an inpatient and outpatient basis.

Comparison shopping is the ideal method for finding the best value in health insurance. Comparison shopping can help determine the true costs of coverage. Comparison shopping can focus on the out-of-pocket costs, deductibles, copays, and co-insurance.

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