Is it good to have a 0% coinsurance?

It’s great to have 0% coinsurance – this means that your insurance company will pay for the entire cost of the visit or session. But note that often, you first have to meet your deductible in order for the coinsurance to kick in – read on below to find out more about deductibles.

Important note:

Most Summary of Benefits will indicate the percentage as the coinsurance amount (e.g. “15%” indicates a 15% coinsurance). However, some insurance plans will have the opposite listed, meaning the amount that the insurance plan covers (e.g. they may list “70%” to indicate that the insurance company covers 70% and you owe a 30% coinsurance). If you notice a high percentage, be sure to check with your plan provider what this percentage means.

What does it mean to have a 100% coinsurance?

Unfortunately, if you have a 100% coinsurance, this means that you are responsible for the entire service fee. This will be paid out-of-pocket and likely does not have any eligibility for reimbursement.

How do coinsurance and deductibles work?

A deductible is the amount set by your insurance plan that you must pay on your own, out-of-pocket, before the insurance company starts helping you pay for costs. For example, if you have a deductible of $1000, this means that you must pay for $1000-worth of services before your insurance company starts covering your costs.

A deductible encompasses all medical costs, so you can reach your deductible by seeing various providers (primary care, specialists, therapists) or by paying for your prescriptions or medical equipment. Often, coinsurance rates begin after you meet your deductible or pay the deductible amount – so if you see that your coinsurance rate for therapist is 50%, check the details to see if this is before or after the deductible.

Does coinsurance go towards the out-of-pocket maximum?

Yes, it does! An out-of-pocket maximum or limit is the highest amount of money that you can pay within a year, determined by your insurance plan, before the insurance company pays for the entirety of your care. So, for example, if you have an out-of-pocket maximum of $5000, once you pay $5000, the insurance company will pay for any subsequent visits, sessions, or prescriptions. And fortunately, copays and coinsurance payments count towards this number!