Coinsurance

What is coinsurance?

Coinsurance is the percentage of the allowed amount that you pay for most medical services and for prescription drugs, when the plan pays less than 100 percent. 

After you’ve paid your deductible, you pay the following percentages for most medical services:

  • For preferred providers: 15 percent of the allowed amount.
  • For participating providers: 40 percent of the allowed amount.
  • For out-of-network providers: 40 percent of the allowed amount, and you may be balance billed.

Read Preferred vs. out-of-network providers for examples of how much you will pay when you see each type of provider.

Note: To learn about how much you will pay for prescription drugs, read the  "Your prescription drug benefit" section in your certificate of coverage.

How much will I pay for medical services?

The table below describes how much you’ll pay for services. Unless otherwise noted, all payment is based on the allowed amount and services are subject to the deductible. Read Summary of benefits to find out which services fall under the standard, preventive, outpatient, inpatient, facility fees, and special categories.

Type of service How much you pay

Standard

Subject to the deductible.

You must pay your deductible before the plan begins to pay. How much you pay (your coinsurance) depends on the provider’s network status:

Preventive

Not subject to the deductible. 

Your coinsurance depends on the provider’s network status:

Outpatient 

Subject to the medical deductible and coinsurance.

If you receive services at a facility that offers inpatient services (like a hospital) but you are not admitted, you pay for outpatient services. See the specific benefit (e.g., emergency room or diagnostic tests) for how much you pay. You may be billed separately for facility fees in addition to the provider fees.

Inpatient

Subject to the deductible.

Most inpatient services require both preauthorization and notification (your provider must notify the plan upon admission to a facility).

Read the "Limits on plan coverage" section in your certificate of coverage to learn more about preauthorization and notification.

Your coinsurance depends on the provider’s network status:

Services are considered inpatient only when you are admitted to a facility (see inpatient stay) .

Facility fees

Facility fees may be charged in addition to provider fees when accessing hospitals or clinics.

Your coinsurance depends on the provider’s* network status:

*A facility, such as a hospital, may be referred to as a “provider” on Explanation of Benefits or facility bills.

Special

(for example, ambulance)

Subject to the deductible

These services have unique payment rules, which are described in the Summary of benefits table in your certificate of coverage.

 

Alert: Even if a provider orders a test or prescribes a treatment, the plan may not cover it. Please review your certificate of coverage or call Customer Service at 1-888-849-3681 if you have questions about benefits or limitations.

 What else do I need to know? 

  • There is no annual plan payment limit. This means there is no limit to how much the plan pays per calendar year.
  • There is no lifetime plan payment limit. This means there is no limit to how much the plan pays over a lifetime.
  • Some services are not covered
  • You don’t need a referral from the plan to see a specialist for most services. However, you will save money by seeing preferred providers, especially for preventive services. 
  • Preexisting conditions: There is no waiting period; medically necessary covered services are eligible for benefits from the effective date of your medical enrollment.