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Out-of-Pocket Healthcare Costs Part 3: Coinsurance

Understanding Health Insurance: Florida Enrollment Basics

Before selecting a healthcare plan, it’s necessary to learn about out-of-pocket costs. When it comes to health insurance, there are several forms of expenses that you may be responsible for. For example, you may be required to pay coinsurance or deductibles. While the payments vary between policies, being aware of these costs helps you select the most appropriate plan. In addition, knowing what you can afford will allow you to narrow down which insurance you can manage monthly. 

Naturally, out-of-pocket costs may seem overwhelming for a healthcare newcomer. Since My Healthcare Direct’s independent experts in health insurance are dedicated and passionate about assisting consumers, we have broken down all the information you need regarding coinsurance. 

For parts 1 and 2 on deductibles and copayments, visit Out-of-Pocket Healthcare Costs Part 1: Deductibles and Out-of-Pocket Healthcare Costs Part 2: Copayments.

image of health insurance card next to stethoscope as a concept image for coinsurance

What is Co-insurance?

Coinsurance refers to the percentage of the cost  a patient must pay for medical expenses. For example, you would pay for hospital/doctor’s office visits or prescription medications. Many insurance plans require the member to cover 100% of out-of-pocket expenses until their deductible is met. 

What’s the Difference Between Copayment & Coinsurance?

Copayments vs. Coinsurance

With out-of-pocket healthcare costs, copayments differ from coinsurance. However, copayments and coinsurance are expenses that patients must pay for a portion of healthcare costs. 

Copayments are fixed dollar amounts you pay for a covered health service after meeting your deductible. For example, suppose your office visit costs $75. Your copayment would be a portion of that total, depending on what the insurance plan covers. So, instead of covering the total, you would cover $20. 

If you haven’t paid your deductible, you will be responsible for the total. Generally, plans with lower premiums have higher copayments. 

In comparison, coinsurance is a predetermined arrangement dictating what percentage the insurance company handles. Specifically, if the provider covers 80% of the total, you must pay the remaining 20%. 

Cost Sharing

Copayments, coinsurance, and deductibles are forms of cost-sharing that insurance companies use to split the overall costs. To make informed decisions regarding your healthcare, it is necessary to understand that how much the insurance pays versus how much you are responsible for depends on the plan’s cost-sharing arrangement. 

Balance Billing

Lastly, for any unsettled payments, providers will submit what’s known as a balance billing. Providers will send members an invoice requesting the remaining balance, which represents the difference between the actual billed amount and the allowed amount. 

Therefore, if the provider’s charge is $200 and the allowed amount is $110, they may charge you the $90 difference. Often, this occurs when you see an out-of-network medical professional. 

Filing A Dispute For Accidental Charges

If you believe you were charged incorrectly, you have the right to file a dispute with your provider using the patient-provider dispute resolution process. This allows an independent third party, a dispute resolution entity, to review your case. 

They will review your case to determine whether the charges were filed wrongfully or you are still responsible for the bill.

Explanation of Benefits Statement

To help you find out about the total charges for your health care services and the cost breakdown for coinsurance, you can request an explanation of benefits statement. Rather than being uncertain about your monthly expenses, the statement allows you to address concerns early on or file a dispute. 

Why You Should Stay In-Network 

Visiting specialists outside your network may result in higher costs. To avoid the additional bills, seek in-network professionals. Otherwise, you may be required to cover a higher percentage of out-of-network coinsurance

If you want to find out which doctors are within your network, contact your insurance company. They will send you a thorough list of professionals you can visit within your area. 

Contact My Healthcare Direct For Additional Information On Coinsurance

If you’re looking for further guidance and information regarding out-of-pocket costs like coinsurance, consult with My Healthcare Direct. Our experienced professionals will provide you with all the details you need to make an informed decision about selecting a healthcare policy. 

Our agents have in-depth knowledge of insurance products, companies, and guidelines. What separates us from other companies is our ability to service our clients and their policyholders proactively. By prioritizing customer service, we ensure their satisfaction. 


Please contact us today to speak with one of our insurance specialists!

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