What is coinsurance?
A covered expense is an eligible expense under a group health insurance plan. A covered expense is an expense incurred by a covered individual that will be reimbursed in whole or in part under the group health insurance plan. For example, under most health insurance plans, doctors’ visits are a covered expense. That is, a doctor’s fee up to the amount provided by the plan will be reimbursed by the insurer Just because an expense is covered does not mean that the coverage is unlimited. Both base plus and comprehensive plans have limits on the expenses for which they will reimburse. In addition, some form of deductible and coinsurance is often applicable. Insurers limit covered expenses in a variety of ways. One way is to cap allowable payments for a certain procedure or service. A common example of this type of limit would be a surgical schedule. Insurers also restrict covered expenses by limiting the number of visits or days for home health care or skilled nursing care, or by establish
Coinsurance is a cost-sharing requirement where you are responsible for paying a certain percentage and the insurance company will pay the remaining percentage of the covered medical expenses after your deductible is met. For a health insurance plan with 20% coinsurance, once the deductible is met, the insurance company will pay 80% of the covered expenses while you pay the remaining 20% until your out-of-pocket limit is reached for the year. Typically, the out-of-pocket limit is the maximum amount you will pay out of your own pocket for covered medical expenses in a given year. For a plan with a $2,000 out-of-pocket limit, you will pay a $1,000 deductible and $1,000 coinsurance while the insurance company covers the remaining $98,000 of the heart surgery bill. Even if you are hospitalized again in the same year, the insurance company will pay 100% of your covered expenses within the limit of the lifetime maximum.
After you’ve met your annual deductible, we share the cost of medical care with you. Coinsurance is the portion that you pay for the cost of a covered service. For example, under a 70/30 coinsurance plan, you are responsible for 30 percent of the cost while Keystone Health Plan East pays the remaining 70 percent, until the out-of-pocket maximum has been reached.
Coinsurance (also known as the deductible) is the percentage of the cost for covered services that are your responsibility. After your deductible limit has been reached, the Plan will pay a stated percentage, based on Reasonable & Customary rates, and you pay the other percentage. Coinsurance is applied to your out-of-pocket maximum.
Related Questions
- I currently have a job and insurance for myself and my son, but after 3 months of my maternity leave if I decide to resign my job, will I be able to get FAMIS for myself and my two sons including my husband who has Obama care?
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- What is coinsurance?
