| First, what is the official definition | | | | deductible was already met. When do you |
| of co-insurance? | | | | stop paying the 30%?? |
| Coinsurance | | | | Stage 3 - The Max Out of Pocket THE |
| Once you have met your deductible, you | | | | CARRIER PAYS 100% |
| pay coinsurance for additional medical | | | | Once you have met your Max out of Pocket |
| care. It is a percentage of the billed | | | | (sometimes called the Copay Maximum), |
| charge. For example, your insurance | | | | the carrier will then pay 100% of |
| company might pay 80%, and then you | | | | covered benefits, in-network. For our |
| would pay 20%. It is similar to a | | | | plan example, let's say we have a $500 |
| co-pay, but is a percentage instead of a | | | | deductible, 70/30 co-insurance, and |
| dollar amount. | | | | $5000 max out of pocket. If we get a |
| Now, let's dig a little deeper. With | | | | $50,000 bill in a calendar year, you pay |
| California health insurance, it is | | | | the first $500, then 30% until you |
| common to speak of their plan as an 80 | | | | reached another $5000 out of pocket. For |
| 20 plan or a 70/30 plan. They are | | | | that $50K, you would pay $5500 and the |
| essentially referring to the | | | | carrier would pay $45,500. Co-insurance |
| co-insurance part of it. With the 80/20 | | | | is nice but the real reason to have |
| example, the health carrier is picking | | | | health insurance is the max out of |
| up 80% of the charges and you are | | | | pocket. |
| picking up the remaining 20%. If there | | | | Co-insurance usually applies to services |
| is any kind of deductible, you must pay | | | | outside of the office visit and |
| that first at 100% until met. | | | | prescriptions. You will typically see |
| Let's take an example and see how | | | | the same co-insurance percentage for |
| California health insurance plans | | | | hospital, lab, surgery, emergency |
| essentially break down into three main | | | | (sometimes has separate additional |
| stages. | | | | copay) and physician services. |
| Stage 1 - The deductible YOU PAY 100% | | | | It's important to stay in network for |
| Let's say you have a $500 deductible. | | | | PPO plans. Let's say you have 70/30 plan |
| Except for services that are separate | | | | and you see a doctor out of the PPO |
| from the deductible (usually office | | | | network on a non-emergency basis for |
| visits and prescriptions...see COPAYS), | | | | $1000 of services and your deductible is |
| you will pay the discounted charges at | | | | already met (you're in Stage 2). Two |
| 100% until you meet your deductible. You | | | | things will probably happen. The health |
| can find more information on | | | | insurance plan will probably have a |
| deductibles. | | | | separate percentage for out of |
| Stage 2 - The co-insurance YOU SHARE A | | | | network...let's say 50/50 instead of 70 |
| PERCENTAGE | | | | 30. Also, the carrier will apply this |
| Once the deductible is met, you then | | | | lesser percentage to what they would pay |
| start sharing the cost with the carrier. | | | | an in-network provider. For example with |
| Let's say our plan is 70/30 and the | | | | the $1000 charge, perhaps the contracted |
| charge is $1000. You pay the first $500 | | | | PPO rate is $600 (discount is usually |
| (deductible) and then you pay 30% of the | | | | 30-60%). The carrier would then pay 50% |
| remaining $500...or $150. Of the first | | | | of the $600 or $300 of the total $1000. |
| $1000 charge, you would pay $650 out of | | | | You pay $700. Compare this with the 30% |
| it. If you have another $1000 charge in | | | | of 600 you would pay for an in-network |
| that same calendar year, you would pay | | | | provider. $700 versus $180 out of your |
| 30% of the 1000 (or $300) since your | | | | pocket. Use in-network providers! |