• What does 0% coinsurance mean when it comes to health insurance?

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    It means that once you reach your deductible, the insurance company pays 100% of the contracted rate for certain covered services. Covered services like physician visits and Rx generally involve a copayment whereas covered services like imaging tests and procedures generally involve coinsurance.

    Often, the simplest way to compare plan costs is to look at all things with a $ next to them as copayments that will be due whether or not you have reached a deductible and all things with a % next to them as obligations due after you reach a deductible. The % items are usually the big ticket items.

    Here’s an example. You have a PPO with a $3,000 deductible and 100% co-insurance. You undergo a coronary procedure that bills more than $20K. You would pay $3,000 (less any payments made toward the deductible in the calendar year) and the insurance would pay 100% of the contracted rate (usually less than the billed amount) for that covered service. Assuming the provider contracts with the insurance carrier, you will only pay your deductible amount. The insurance company will pay the contracted rate less the amount you pay (up to $3K).

    The provider must contract with the insurance carrier (you must be “in network”) to get the full benefit of 0%/100% coinsurance. Usually, there is a separate coinsurance percentage for out of network providers. It is possible there is no payment at all for out of network providers. Elective procedures, distinct from services performed out of network, may not be paid at all.

    0% coinsurance is rare and high (conservative for the insured) in today’s insurance market. It is less rare for HMO plans than PPO plans. A coinsurance amount of between 10 and 50% is common.

    I recommend seeking advice from a professional for a complete understanding of how coinsurance works and applies to your situation.

    It means that the cost of medical care is paid completely by the insurance, with no contribution by the policyholder.

    You may however have a deductible, which, in the case of health insurance, refers to the total amount per year you must pay yourself before insurance applies at all. Once that deductible has been paid, then all covered medical costs will be paid by the insurance company for the rest of the year, subject to any coinsurance. Coinsurance refers to the total percentage of the cost paid by you. If it is 0%, then you pay nothing.

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    It means you are responsible for 0% of the out of pocket expenses after your deductible is met. If you had a 10% coinsirance, you would be responsible for 10% of the medical expenses after the deductible is met, until you reach the out of pocket maximum, not including copays and out of network expenses.

    Coinsurance is the percentage of covered medical expenses that you are required to pay after the deductible. Let’s say your health insurance plan has a 20%coinsurance requirement (excluding additional copays). … Some plans offer 0%coinsurance, meaning you’d have no coinsurance to pay.

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    Coinsurance is the amount of the bill you are responsible for if your co insurance percentage is 10% and a bill is 100 dollars you will pay 10 dollars towards your bill. Because your part of a bill is a set percentage you coinsurance amount. It continues to apply even after all deductibles have been paid.

    Some have a copay in addition to this as well.

    Some companies are starting eliminate this from plans because it’s confusing for many people.

    Some plans with coinsurance might have a slightly different structure it’s good to know what yours is.

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    It means the insured does need to pay shared price of amount charged to insurance. For example: you need to buy a prescription drugs for USD 100 using insurance. If the policy say 10% coinsurance, you will need to pay USD 10, and the rest will be paid by insurance.

    My wife and I are discovering the differences between Medicare and employer-sponsored group insurance; she is already enrolled, and I will be in a few months. We are moving from a Silver HMO plan with a very limited network, so our experience is influenced by that plan’s advantages and shortcomings.

    There are many differences, some subtle, some more obvious:

    First, one insurance plan is no longer enough. In addition to basic Medicare (parts A & B), a new enrollee needs at least one, and potentially several, supplemental plans to fill the gaps in classic Medicare.

    Then, there’s the choice between cost and accessibility. Since we were completely disgusted by the idea of having such a limited network — for example, my wife could not get a mammogram in our entire county despite there being plenty of imaging centers around us — we opted for a “Medigap” plan instead of a significantly less expensive “Advantage” plan. This meant that we also had to find a Part D prescription plan. So now we have to deal with 3 different insurance providers — three times the fun ;). But the advantage is that we no longer have to spend hours searching through our insurance network for specialists and facilities and calling ahead to verify that they still accept our insurance.

    Then there’s the infamous “donut hole” in prescription coverage[1]. Both my wife and I are pretty good with math, but we can’t understand the series of numbers presented on our prescription form, there’s no obvious logic or algebraic formula that we can find to explain them. We’ll just have to be unpleasantly surprised when the copay for the one expensive medication my wife takes changes drastically from each month to the next.

    Then there’s the challenge that many preventive and diagnostic tests are not covered, but sometimes they can be. We have already run into this, and the billing person assured us that they would ensure to code the test as medically necessary and not just exploratory.

    I’m sure there are many more adventures just waiting in store for us :).

    Footnotes

    It means you’re likely paying a whole lot of money in premiums in order to have a false peace of mind if/when you go to the doctor.

    Here is a comparison of the three health insurance options currently being offered by my wife’s employer.

    Note the first option is a high deductible plan eligible to be used along with an HSA. The last plan in the list is similar to the one you’re talking about. Notice the total in premiums, the amount you typically have taken out of your paycheck that you pay even if you don’t go to the doctor, is about $3,000 more per year than the premium for the high deductible plan.

    Even if you go to the doctor, and have surgery, and need to go to the ER or have a baby, you will end up paying less overall with the high deductible plan than with the plan you are referencing. You’re basically throwing money away when you choose the plan you’re referencing, especially if you hardly ever go to the doctor.

    You’re much better off choosing the high deductible plan, and then instead of paying the higher premium, use the money you would have spent on the premium to fund an HSA. You can then use money in the HSA to pay your doctor bills if/when you go. Who knows, you may not even use all of the money you put in the HSA, and then it will roll over to the next year and the next, so it’s there when you need it. It may even last until you retire, at which point it becomes like an IRA and you can use the money for anything you’d like.

    A few thoughts to add to other answers: First, in my experience, coinsurance usually applied only to a few specific types of care, not to everything. For those items, with 100% counsurance, the covered person pays 100% of the cost (but at the price the carrier pays, not the (much higher) retail cost), until the out of pocket maximum is reached. I never saw a 100% counsurance- 50% was more typical – but 100% coinsurance is better than a blanket exclusion of coverage, which would mean that the carrrier will never pay for that item or service.

    Second, another answer got the concept of “reasonable and customary” wrong. That language does not limit your choice of provider, but instead limits the amount that the carrier will pay to the provider. In some policies, the provider is able to “balance bill,” meaning that you owe the provider the difference between what the carrier pays and what the provider charges. Carriers (and some providers) usually try to work it out so that the insured person doesn’t have to pay. Many policies these days have a defined network of providers, which means that services from providers outside that network are not covered without special permission. Providers within the network, though, are almost always prohibited from balance billing except for copayments, deductibles and (yeah) counsurance.

    Finally, in addition to your HR person (for work-based coverage), the member or customer service department at your carrier can answer your questions about coverage. That’s easier, and maybe more accurate than going to your HR person.

    I recommend that you wait until you are fully enrolled in the plan with your new employer before cancelling the individual plan you have under the Affordable Care Act (ACA). There are two reasons for that recommendation:

    1. You never know what could happen to your job offer or insurance coverage with the new employer. There is no reason to give up the insurance you have before you secure new insurance.
    2. Your individual coverage under the ACA has a 90-day grace period. That means that your coverage will not be cancelled for the first 90 days after you stop paying the premium. You can wait to pay or cancel the individual plan until after you are sure that you have new coverage with your employer. The individual plan will still pay claims for the first 30 days after you stop paying premiums and will still allow you to catch up the premium payments without cancellation for up to 90 days.

    So, if your employer coverage is supposed to start on 1/1/21 then don’t pay the individual premium due for 1/1/21, but also don’t cancel the coverage, the 90 day grace period will start at that point. After you have secured coverage with your new employer you can then cancel the individual plan effective as of 1/1/21 after the fact. If worst case happens and the employer coverage is never put in force, then you can still make up the past due payment(s) on the individual plan within the 90 days, and not have any gap in your coverage.

    “100% coinsurance” means you pay 100%. The official definition can be found here: Coinsurance – HealthCare.gov Glossary. It also has a good sample that I copied here for completeness of this answer:

    “Coinsurance is …

    The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.

    Let’s say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%.

    • If you’ve paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
    • If you haven’t met your deductible: You pay the full allowed amount, $100.

    Example of coinsurance with high medical costs

    Let’s say the following amounts apply to your plan and you need a lot of treatment for a serious condition. Allowable costs are $12,000.

    • Deductible: $3,000
    • Coinsurance: 20%
    • Out-of-pocket maximum: $6,850

    You’d pay all of the first $3,000 (your deductible).

    You’ll pay 20% of the remaining $9,000, or $1,800 (your coinsurance).

    So your total out-of-pocket costs would be $4,800 — your $3,000 deductible plus your $1,800 coinsurance.

    If your total out-of-pocket costs reach $6,850, you’d pay only that amount, including your deductible and coinsurance. The insurance company would pay for all covered services for the rest of your plan year.

    Generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.

    Yeah, so now if you see “X% coinsurance”, that X% is how much you pay.

    This example above describes “X% coinsurance after deductible”. In your question, “100% coinsurance with no deductible” basically means you have to pay the full cost out of your pocket (until reaching out-of-pocket maximum). For this kind of plan, the monthly premium is generally low, but you have to pay a lot out of your pocket if you were hit by a huge bill.

    Now I’m speculating why this is confusing for many people (including other answer to this question). This term is relatively new, only came into wide use after the Affordable Care Act. Before that people had used “100% after deductible” for a long time, which means that the insurance company pays 100% after you pay the deductible. Adding a single word “coinsurance” changed the meaning completely and, as we can see from the sample above, means you pay 100% after paying deductible.

    Misleading from the insurance industry? I leave it for you to judge.

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