What Is Co-Insurance? How Does It work?

Have you ever heard of co-insurance? If not, this article will help you to understand what coinsurance is and how it works.

Co-insurance is a clause that is generally utilized by insurance providers that makes sure that your property is sufficiently covered, whether that is for actual cash value or the replacement cost. It helps to give the guarantee that your insurance provider is charging a justified premium for a specific risk. It is the amount generally expressed as a fixed percentage. An insured must require pay against a claim after the deductible is satisfied.

Coinsurance is an amount that is typically expressed as a predetermined percentage that you will require to pay against a claim after the deductible is paid out. If you are planning to take co-insurance, but you are not familiar with it, follow this article to know the details. It will help you to find out how it works.

What is co-insurance?

Coinsurance is an agreement between an insurance company and a business holder to share the cost of a claim. In coinsurance, the policyholder is required to hold a high enough insurance limit to cover a percentage of the property value to receive full compensation if there is a loss or damage to the property. It is a form of cost-sharing or splitting the cost of a service or medication between the insurance company and the consumer.

If you go for 20% coinsurance, that means your insurance company will pay for 80% of the total cost of service. In this case, you will be responsible to pay the remaining 20%. But if you have not paid your deductible, then you will have to pay the full allowed amount. Coinsurance can apply to special procedures, medications, and office visits. Many property insurance plans include some kind of co-insurance obligation. If your property is underinsured, there will be a coinsurance penalty you are required to pay. To further understand what coinsurance means, check out the example below:

If you take out a health insurance policy with an 80/20 coinsurance provision, a $1,000 out-of-pocket deductible, and a $5,000 out-of-pocket maximum. Unfortunately, you require an unexpected outpatient surgery early in the year that costs $5,500. Because you have not paid your deductible, you must pay the first $1,000 of the bill. After meeting your $1,000 deductible, you are then supposed to pay 20% of the remaining $4,500, or $900. Your insurance company will cover 80% of the remaining cost.

How does it work?

One of the most well-known coinsurance breakdowns is the 80/20 split. It works under the terms in which the insured is responsible for 20% of medical costs, while the insurer pays the remaining 80%. It applies only after the insured has reached the terms’ out-of-pocket deductible amount. Coinsurance also applies to the level of property insurance that an owner must buy on a structure for the coverage of claims as per their policy.

To know how coinsurance works, suppose you had an eye infection and your primary care physician could not provide you the full treatment and had to refer you to an eye specialist. Your visit to the specialist costs $120 so you will have to pay $24 (20% of $120) and your insurance company is responsible to pay the remaining $96 of the bill. The specialist prescribed you some medication for your eye, so you head toward the pharmacy to get it. The prescription costs $60 and you are asked to pay $12 out of pocket. It means your insurance takes care of the remaining $48.

Before buying an insurance plan, it is essential to understand the terminology around coinsurance and what you are obligated to pay under your insurance plan. A licensed agent can help to understand and make things clear about different plans as different plans cover different percentages.

Coinsurance clause

A coinsurance clause ensures policyholders insure their property to an appropriate value and that the insurer receives a fair premium for the risk. It is usually expressed as a percentage. It is a common and misunderstood part of property insurance policies. The insurance company agrees to reduce the premium on a policy if you carry insurance equal to a specific percentage of the property’s true value which is usually 80% to 90%.

If you don’t insure your property at the specified percentage, almost 80% of its value, you can face a coinsurance penalty. Your losses can still be covered but only for the percentage, you expect. In the coinsurance clause, some policies require 100% of the value to be insured. The coinsurance can be suspended for the term of the policy by adding an agreed or stated amount endorsement. It is a provision where the insurer and the insured agree to an amount of insurance and the coinsurance clause is not applied to a loss. This type of coinsurance is called the 100% coinsurance clause.

Coinsurance and reinsurance

Coinsurance refers to sharing one risk amongst multiple sharing companies whereas reinsurance is providing insurance for the risk that has been already taken up by an insurance company. Reinsurance is considered as the transfer of a part of the risk taken by the direct insurer to another insurer. Although both of these terminologies are associated with the insurance sector, there are differences many people do not know.

Difference between coinsurance and reinsurance

  • Reinsurance is a type of insurance purchased by an insurance company to mitigate the risk of loss whereas coinsurance is the participation of one or more insurance companies to cover the same risk.
  • The risk covered under coinsurance is the same for all the participants and is agreed upon under mutual agreement whereas, with reinsurance, an insurance provider can limit themselves from the potential loss of amount.
  • Coinsurance commonly comes into the picture when the volume of business to be covered is beyond the capacity of a single insurance provider. On the other hand, with a reinsurance policy, the insurance providers can protect themselves from financial ruin and also protect the companies’ customers from unforeseen uncovered losses.
  • In coinsurance, the risk is directly divided amongst the insurers as per the predetermined agreement while with the help of reinsurance, insurance companies lower their risk of catastrophic events like a financial debacle.

Coinsurance means in medical billing

In medical billing terms, coinsurance means the percentage of treatment costs that you bear after paying the deductibles. A co-insurance plan is also used in medical and dental insurance. Many health and dental policies cover your medical or dental costs according to a specified ratio such as 80/20 or 70/30 depending upon the plan you chose. This amount is usually offered as a fixed percentage. The coinsurance plans come with features in which the percentage of coinsurance remains fixed. It helps to protect insurers against large claims or penalties.

In this plan, the policyholders need to pay their deductible amount before their coinsurance plan comes into play. In addition, the percentage adheres to the out-of-pocket maximum that you can pay for a year before your insurance policy pays the rest of it.

For example, If your coinsurance is 20%, then you are liable to bear 20% of the treatment cost while the remaining 80% is required to be borne by your insurance provider. It lowers your expenses. Suppose your expenses towards treating a certain disease are Rs.10,000, you have to pay Rs.2000 while Rs.8000 is required to be covered by your insurance policy. But you can be facilitated after you pay your deductibles.

What are deductibles?

In terms of insurance, the deductible is the amount that needs to be paid out of pocket by the policyholder before an insurance provider pays any expenses. The term ‘deductible’ is used to describe one of several types of clauses that are used by insurance companies as a threshold for policy payments.

You have to pay the amount (deductible) each year for most eligible medical services or medications before your health plan begins to share the cost of covered services. For example, if you have a $1,000 yearly deductible, you are required to pay the first $1,000  of your total eligible medical costs before your plan helps to pay. If you have only employee medical coverage, then once you have enough expenses to meet the deductible, you move into the coinsurance phase of your coverage.

What is the co-insurance rule?

The co-insurance clause forms part of a commercial property insurance policy and is imposed by insurers to encourage the policyholder to carry a limit of insurance that is equal to the value of the property being insured or at least equal to a specified percentage of the value of the property.

In property insurance, the rule of coinsurance is based on the concept of insurance to value, meaning the ratio of your insurance limit to the value of your insured property. It means that you must purchase a policy limit that meets or exceeds the coinsurance percentage. For example, if you have an 80% coinsurance clause and a building that costs $1 million to replace, you need to purchase at least $800.000 in coverage.

If you fail to purchase the coverage required by your coinsurance clause and there’s a loss, your insurance company might reduce your claim payment. You can avoid coinsurance by purchasing agreed value coverage or by using value reporting.

What is the benefit of coinsurance?

The benefit of coinsurance is that, if the out-of-pocket maximum is achieved by the insured in the early phase of the year, then the entire cost of the claim is borne by the insurer. Some insurance companies offer lower premiums with high deductibles and out-of-pocket maximums. There is a great way for insurance companies to pass on the burden of the insurance claim.

Health plans with higher coinsurance generally have lower monthly premiums. That’s because you take more risks, so you will find that most health plans with 70/30 coinsurance have lower premiums than an 80/20 coinsurance plan. It is a great benefit of coinsurance for the individual to choose a 70/30 plan.

In the case of 100% coinsurance, once your deductible is reached, your provider will pay for 100% of your medical costs without requiring any coinsurance payment. In this way, the insured will be burden free and get relief from heavy expenses.

What is coinsurance on a claim?

Coinsurance on a claim means the percentage of costs of covered health care services you pay (20% for example) after you have paid your deductible. Suppose your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%. If you have paid your deductible, you pay 20% of $100, or $20 only.

The higher your coinsurance is, the more you have to pay out of pocket. Keep one thing in mind that a plan with higher coinsurance usually has lower monthly premiums. You may use the coinsurance formula to calculate coinsurance. It is relatively simple. Start by dividing the actual amount of coverage on the house by the amount that should have been carried (80% of the replacement value). Then multiply this amount by the amount of the loss, this is how you will get the amount of the reimbursement.

Difference between coinsurance and copay

Coinsurance and copay are two different terms. Coinsurance is the percentage of costs that you pay after paying out your deductibles whereas copay is a set rate you pay for the prescriptions, doctor visits, and other types of care and treatments. Copays are a fixed dollar amount that is almost always less expensive than the percentage amount you would pay. A copay plan is better than a coinsurance plan.

A copay is a set amount of pay whenever you use a particular type of healthcare service. You may pay a copayment in addition to your monthly premium. Some health insurance companies negotiate for discounted rates from their providers, in this situation, you pay the coinsurance at the discounted rate. Once you pay the copay for a qualified service, your health insurance provider is responsible to pay the remaining costs of your service whereas the amount you are responsible for is based on the total rate of service. It makes coinsurance less predictable than copayments.

The benefit of a coinsurance plan is that many health insurance companies will count the fees as part of your maximum out-of-pocket expenses whereas copays typically do not count toward maximum out-of-pocket expenses. Always search a plan’s benefits summary for specifics. Make sure to thoroughly understand the terms and conditions of the plan.

Out-of-pocket maximums

Out of pocket expenses are healthcare costs that are not covered by an insurance plan. For example, if your expenditure has not yet reached your plan deductible. The out-of-pocket maximum is the maximum amount of out-of-pocket expenses that you require to pay in one year. Once you reach your out-of-pocket maximum, your health insurance plan covers 100% of all the covered services for the rest of the year. All money that you spend on deductibles, copays, and coinsurance count towards your out-of-pocket maximum.

However, the premiums don’t count and neither does anything that you spend on services that your plan does not cover. There is a chance that you may have two out-of-pocket limits, an individual one and a family one.

What do out-of-network and in-network mean?

Out-of-network insurance means that your doctor or physician does not have a contract with your health insurance plan provider. Sometimes, it can result in higher rates. Some health plans, such as an HMO plan, do not cover care from out-of-network providers at all, except in an emergency. The coverage your plan offers for in-network and out of network health care providers, and the network your provider is in, both puts an impact on how much you pay for care. There is a completely separate deductible and coinsurance rate for the anthem plans when out-of-network providers are used.

In-network providers are doctors or medical facilities with which your plan has negotiated specific rates. Out-of-network providers are everything else and they are usually much more expensive. In-network doesn’t mean close to where you live. You can even have a North Carolina plan and see an in-network provider at the Cleveland Clinic in Ohio.

Whenever possible, make sure that you are using in-network providers for all of your healthcare needs. If there are certain doctors and facilities you like to use, ensure that they are part of your plan’s network. If not, it may make financial sense to switch plans during the next enrollment period.

Coinsurance clause effect

The coinsurance clause has no effect unless it comes to a property loss. If the loss occurs, the insurer compares the insurance limit on your policy to the amount of insurance you require to purchase based on the coinsurance percentage. If you purchase less than required, there is a possibility that the insurance company might reduce your claim payment in proportion to the difference. If you purchase 10% less than required, the insurance company might pay 10% less.

Co-insurance clauses encourage businesses to buy adequate insurance plans. If coinsurance clauses do not exist, some policyholders may try to save money on premiums by insuring their property for only a portion of its value. Thus, policyholders might have insufficient insurance to cover big losses. Coinsurance encourages policyholders to insure their property at or near its full value. Mostly, the policyholders buy full limits of insurance so the insurers collect more premium dollars and may charge lower rates overall.

In a commercial property policy, the coinsurance clause is usually found in the policy conditions section. The fact that your policy contains such a clause does not mean that your policy is subject to a coinsurance plan. Coinsurance applies only in a situation if a coinsurance percentage is shown in the policy declarations.

Property coinsurance

The coinsurance clause is also found in many insurance policies, such as commercial property, dwelling forms, homeowners, federal flood, health insurance, and at times even directors and officers liability policies. The use and effect on the insured may be different in each type of policy. The coinsurance requirement in a property insurance policy may become a specific reason for insurance recovery that is less than the insured expected.

Coinsurance in property insurance is a way for insurers to obtain rates and premium quality. The property insurance clause must have a standard in which to apply expected losses based on past loss experience over an entire underwriting book. It is accomplished by getting the exposure base on a common basis for all property insurance insureds including replacement cost, actual cash value, and actual loss sustained.

A coinsurance condition in a property insurance policy is analogous to the need for a standard definition of “payroll” to compute worker’s compensation premium. All workers compensation insurers use the same “payroll” definition established by workers compensation rating bureaus. This is how all worker’s compensation insureds report their insurable exposure on the same basis.


Read the information about coinsurance which is a clause that is utilized by the insurance providers to make sure that your property is sufficiently covered. Choose the best coinsurance plan whether that is 80/20 or 70/30. Also, check out the policy before buying any plan and thoroughly understand the terms and conditions. Choose the plan which is more beneficial and is according to your premiums. Know the differences between coinsurance, reinsurance, copays, and deductibles.

Tony Bennett

Tony Bennett

Tony Benett makes his living in the insurance industry by teaching and consulting. He is also recognized by the legal profession as an expert on insurance coverages. His insurance experience includes having worked at the company level, owned an independent general agency and having worked for an insurance association. He has received various certificates over the past few years and helps his clients and readers by giving them a realistic outlook on what they can expect to achieve within their set targets. At Insurance Noon, he is known for his in-depth analysis and attention to details with accuracy. He has been published as one of the most referred agents by his peers in the insurance community. Tony loves the outdoors and most sport events. His passion other than providing excellent advice is playing golf.

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