Your 2020 Coinsurance Guide

Once you sign up for a health insurance plan, you are immediately expected to start monthly premium payments. Then, if you incur medical expenses such as lab work, you are expected to pay these expenses, contributing to your ‘deductible.’ A deductible is an amount you have to pay before your insurance starts paying a percentage. Then, once you are finally all caught up with your deductible, your insurance policy covers the rest of your claims, right? Well, kind of, unless your policy has a coinsurance clause. 

Once your deductible is met, any insurance-covered procedure, treatment or service will result in a medical expense. This is called coinsurance. Your insurance company will pay a large portion of any bill (after your deductible is met), and you are responsible for the rest. There are different breakdowns for how the coinsurance is paid for.

Coinsurance is a great option for people needing a little extra help.

How It Breaks Down

The divisions in coinsurance policies are usually broken down into 70/30 or 80/20. What this means is the insurance company will pay 70% or 80%, and you will pay the remaining 30% or 20% out of pocket. The most common coinsurance breakdown is 80/20.

This will only apply once your deductible is met. If you have a $1500 deductible, then you must pay this off first before activating the coinsurance.

Now, let’s use an example. If your medical bill is $2,000 and you have a $1,000 deductible, then the portion of the bill that the coinsurance will apply to is $1,000. With a 20% coinsurance, you will pay $200 extra. In total, the $1,000 deductible plus the $200 remaining of the coinsurance will equate to $1,200 out of pocket. 

Now if your deductible was already met and you had that same procedure that was $2,000, then you would have to pay 20% of it. The sum total of $400 out of pocket, since the insurance company paid $1,600 of the service.

Out-of-Pocket Maximum

Now, to throw a wrench into things, health insurance companies offer plans with an out of pocket maximum- but this will work in your favor if you have coinsurance. Once you reach your out of pocket maximum, then the insurance company will pay for any following services 100%. 

For example, if you have a $5,000 out of pocket maximum, then the $1,000 deductible you paid goes towards that. This leaves you with only $4000 left to pay. Every 20% or 30% you pay in coinsurance goes towards your out of pocket maximum. 

If you have surgery that costs $20,000, then you will have to pay a 20% coinsurance of $4,000. Once you pay that off, including the previous $1,000 deductible, then you can not be charged for anything further out of pocket. The out of pocket max will have been satisfied and the insurance company must pay any following services fully.

money saved from using coinsurance
Think of the money you’ll save by using this insurance method–paying completely alone could be devastating.

Because policies are renewed annually, once the new year begins, then your deductible restarts, and you will have to meet that price again. Some people have to deal with coinsurance, while others just have to pay their deductible and the insurance company will pay the rest.

In order to find a plan that meets your budget, and needs, speaking with an agent will help. They can help guide you in the best direction, and explain to you thoroughly how much everything will be. You can discuss with them coinsurance, and if you would like a plan that has one or doesn’t. To speak to one of our highly trained agents in your area call 888-350-1890, or email us at Or to get instant quotes, enter your zip code in the bar above. Health insurance has so many different variables. Let us make it more simple and easy for you. 

PA’s ACA Health Insurance Rates Go Up

A new year means new rates. This is especially true for health insurance, and more so in the state of Pennsylvania. The ACA Marketplace individual plan costs are going up for PA next year by 4%, according to data. Small group market plans are increasing by about 9.6%. Although there is an increase within the rates, about 19 counties will see more insurance plans to choose from.

“It’s a slight increase, but it’s not double-digit increases,” said Antoinette Kraus, executive director of the Pennsylvania Health Access Network. The group helps consumers find plans with state-approved navigators. “Pennsylvania has actually really worked hard to shield consumers from those steep rate hikes that happened in other parts of the country for the past few years.”

ACA insurance increases on an ipad
Thankfully, the increase isn’t that big. It should be something everyone can accommodate.

State Insurance Commissioner Jessica Altman said more insurers have entered PA’s ACA marketplace, and returning insurers have provided more options and flexibility in their benefits. Altman believes the increase in rates in the state are in line with the average rate increases nationwide. “Our expanding marketplace encourages consumers to shop around and generates lower costs through competition,” Altman said.

The biggest concern is that people will opt for plans that do not comply with the ACA standards such as the 10 essential health benefits: 

  1. Ambulatory patient services
  2. Prescription drugs
  3. Emergency care
  4. Mental health services
  5. Hospitalization
  6. Rehabilitative services
  7. Preventative and wellness services
  8. Laboratory services
  9. Pediatric care
  10. Maternity and newborn care

A company new to the state, Oscar Health, will be an option in Bucks, Chester, Delaware, Philadelphia, and Montgomery counties. This will bring more options to consumers shopping for plans.

And Highmark, another company seeing change, is now offering plans within 14 new central PA counties, including in Fayette and Greene counties. Prior to this, all these counties operated with one insurer. This will put Highmark head-to-head with UPMC Health Plan. UPMC is in 53 counties in the western and central regions of the state.

Mark Nave, Highmark’s senior vice president of individual and small group markets, said Thursday the insurer will be introducing a new ACA plan called Together Blue EPO Silver 2900. This will be available in 2020.

doctors looking at a scan and talking about marketplace rates
Costs for healthcare can build it, so make sure you know which premiums are affected by these changes.

 For a 40-year-old, the plan would carry:

  •  a $349 or so premium
  •  a $40 copayment for physician office visits after two free visits
  •  a $25 copayment for Tier 1 prescription drugs
  •  a $2,900 yearly deductible

“Only about 9,000 Pennsylvanians live in counties that only offer one health insurer option in ACA plans, down from nearly 180,000 people who lived in counties without multiple insurers in 2018,” Altman said.  PA’s governor, Tom Wolf, added, “The state has an uninsured rate of just 5.5%, which is the lowest ever in Pennsylvania.”

With all the new companies and plans coming into the state, there should be expanded health insurance options for many Pennsylvanians. In turn, this would hopefully increase the number of people insured. The Affordable Care Act exchange enrollment period for 2020 coverage is from November 1 until  Dec. 15 to sign up for a plan.