What is coinsurance?

When we enter the subject of insurance, sometimes we find words and expressions that we do not know or do not fully understand. To know what is coinsurance It will help you understand some of the most common terms and conditions of insurance policies.

What is coinsurance?

Coinsurance is an amount, usually expressed as a fixed percentage, that an insured must pay on a claim after the deductible. In health insurance, a coinsurance provision is similar to a copay provision, except that copays require the insured to pay a fixed dollar amount at the time of service. Some property insurance policies contain coinsurance provisions.

What is coinsurance?

How coinsurance works

You know what is coinsuranceLet’s see how it works below.

One of the most common terms of coinsurance is the 80/20 split. Under the terms of an 80/20 coinsurance plan, the insured is responsible for 20% of medical costs, while the insurer pays the remaining 80%. However, these terms only apply after the insured has met the deductible amount stated in the policy. Also, most health insurance policies include an out-of-pocket maximum that limits the total amount the insured pays for care in a given period.


  • Copay plans can make it easier for members to calculate their out-of-pocket costs because it is a fixed amount.
  • Coinsurance typically splits costs with the insured 80/20 percent.
  • With coinsurance, the insured must pay the deductible before the company covers their 80% of the bill.

Coinsurance Example

Suppose you purchase a health insurance policy with an 80/20 coinsurance provision, a $1,000 deductible, and a $5,000 out-of-pocket maximum. Unfortunately, you need an outpatient surgery at the beginning of the year that costs $5,500. Since you haven’t met your deductible yet, you must pay the first $1,000 of the bill. After you meet your $1,000 deductible, you’ll be responsible for only 20% of the remaining $4,500, or $900. Your insurance company will cover 80%, the remaining balance.

If you require another expensive procedure later in the year, your coinsurance provision kicks in immediately because you’ve already met your annual deductible. Also, since you’ve already paid a total of $1,900 out of pocket during the policy period, the maximum amount you’ll have to pay for services for the rest of the year is $3,100.

Once you reach the $5,000 out-of-pocket maximum, your insurance company is responsible for paying up to the maximum policy limit, or the maximum benefit allowed under a given policy.

Coinsurance also applies to property insurance that homeowners must purchase to cover damage from breakdowns, accidents, or even some weather events.

copay vs. Coinsurance

Both copayment and coinsurance provisions are ways for insurance companies to spread risk among the people they insure. However, both have advantages and disadvantages for consumers. Because coinsurance policies require deductibles before the insurer bears any costs, policyholders absorb more costs up front.

On the other hand, the out-of-pocket maximum is also more likely to be reached earlier in the year, causing the insurance company to incur all costs for the remainder of the policy term.

Copay plans spread the cost of medical care over a full year and make it easy to predict medical expenses. A copay plan charges the insured a fixed amount at the time of each service.

Copays vary depending on the type of service you receive. For example, a visit to a primary care physician may have a copay of $20, while a visit to the emergency room may have a copay of $100. Other services like preventive care and screening exams may require payment in full without a copay. A copay policy is likely to make an insured pay for each medical visit.

Property Insurance Coinsurance

The coinsurance clause in a homeowners insurance policy requires that a home be insured for a percentage of its full cash or replacement value. Typically, this percentage is 80%, but different providers may require different coverage percentages. If a structure is not insured up to this level and the owner files a claim for a covered peril, the provider may assess the owner a coinsurance penalty.

For example, if a property is worth $200,000 and the insurance provider requires 80% coinsurance, the owner must have $160,000 of insurance coverage on the property.

Homeowners can include a coinsurance waiver in policies. This clause implies that the owner waives coinsurance. Generally, insurance companies tend to waive coinsurance only for fairly small claims. However, in some cases, policies may include a waiver of coinsurance in the event of a total loss.

What is coinsurance: summary

Coinsurance is the amount an insured must pay against a health insurance claim after their deductible has been met. Coinsurance also applies to property insurance that homeowners must purchase to cover potential property damage. Coinsurance differs from a copayment in that it is generally a fixed dollar amount that an insured must pay at the time of each service. Both copayment and coinsurance provisions are ways for insurers to spread risk among the people they insure. However, both have advantages and disadvantages for consumers.

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