Coinsurance
The allowed amount is the price your health plan agrees to pay for a service. Your plan uses this price (not what the doctor charges) to figure out what you pay.
Last updated: September, 2026
Key Takeaways
- Coinsurance is your share of the cost for covered services.
- It is a percentage, not a flat fee.
- Coinsurance usually applies after you meet your deductible.
- Your coinsurance is based on the health plan’s allowed amount, not the doctor’s full bill.
- Using in-network providers usually keeps your coinsurance costs lower.
What is Coinsurance?
Coinsurance is the part of a medical bill that you pay after your deductible is met. Instead of a flat copay, coinsurance is a percentage of the allowed amount for a service.
For example, your health insurance plan may pay 80% and you pay 20%. Coinsurance can apply to services like doctor visits, lab tests, imaging, hospital care, and prescriptions. The exact percentage can be different depending on the service and whether you use an in-network provider. Understanding coinsurance helps you estimate what you may pay when you receive care.
How This Shows Up in Real Life
Let’s say you already met your deductible and need an imaging test. The provider bills $250, but your health plan’s allowed amount is $140.
If your coinsurance is 20%, you pay $28 and your health plan pays the remaining $112.
Service Cost Example | Amount |
|---|---|
Provider bill | $250 |
Allowed amount | $140 |
Your coinsurance (20%) | $28 |
Insurance plan pays (80%) | $112 |
Your coinsurance is based on the allowed amount, not the original bill.
How Coinsurance What You Pay
Coinsurance affects how much you pay each time you receive care after your deductible is met. Lower coinsurance means your health insurance plan pays a larger share of the bill. Higher coinsurance means you pay more when you use services.
The amount you pay depends on the allowed amount for the service and the coinsurance percentage in your health insurance plan. Because of this, your cost can be different for different types of care, such as doctor visits, tests, or hospital services.
Coinsurance also counts toward your out-of-pocket maximum. Once you reach that yearly limit, your health plan usually pays 100% of covered in-network services for the rest of the insurance plan year.
Where to Find This in Your Plan Details
To check your coinsurance amounts, review:
- Your Summary of Benefits and Coverage (SBC)
- Your Schedule of Benefits
- Your member handbook or policy documents
- Your health plan’s website, your Ambetter Health online member account, or the mobile app.
These documents show the percentage you pay for different services, such as hospital care, tests, or prescriptions.
Coinsurance vs Copay vs Deductible
Coinsurance, copays, and deductibles are all ways you share the cost of care in a health insurance plan. Each one works differently and affects what you pay at different times.
Cost Type | What It Is | When You Pay |
|---|---|---|
Coinsurance | A percentage of the allowed amount for a service | After you meet your deductible |
Copay | A fixed dollar amount for a service | Usually at the time of the visit |
Deductible | The amount you pay before your insurance plan starts sharing costs | Before coinsurance usually applies |
How This Changes Across Marketplace Plans
Coinsurance levels can be different depending on the coverage category you pick. Marketplace plans are grouped into metal levels, which help show how costs are shared between you and your health plan.
Insurance plans with lower monthly premiums usually have higher coinsurance. Coverage with higher premiums often have lower coinsurance when you receive care.
Insurance Plan Category | Typical Coinsurance Level | What It Means for You |
|---|---|---|
Bronze | Higher coinsurance | Lower premiums, but you may pay more when you get care |
Silver | Moderate coinsurance | Balanced monthly cost and out-of-pocket costs and may be eligible for cost-sharing reductions (CSRs) |
Gold | Lower coinsurance | Higher premiums, but lower costs when you receive services |
Platinum | Lowest coinsurance | Highest premiums, but more predictable costs for care |
FAQs About Coinsurance
No. A copay is a fixed amount you pay for a service, such as $30 for a doctor visit. Coinsurance is a percentage of the allowed amount for the service. The amount you pay can change depending on the total cost of the care.
Usually not. In most health insurance plans, coinsurance starts after you meet your deductible. Before that, you may pay the full allowed amount for the service until your deductible is met.
Not always. Some services use copays instead of coinsurance. Preventive care may also be covered without coinsurance when you use in-network providers. Your coverage documents explain which services use coinsurance and which use other types of cost sharing.
Yes. The amount you pay through coinsurance usually counts toward your yearly out-of-pocket maximum. Once you reach that limit, your insurance plan usually pays the full cost of covered in-network services for the rest of the insurance plan year. This limit helps protect you from very high medical costs.
Yes. Coinsurance percentages can be different depending on the type of care. For example, hospital care may have a different percentage than lab tests or specialist visits. Checking your coverage details can help you understand what you may pay for different services.
Related Terms
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What Is Cost Sharing in Health Insurance?
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What Is an Allowed Amount in Health Insurance?
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Learn MoreHave Questions About How This Works with Your Ambetter Health Plan?
Already covered? Your benefits vary by plan and location. Limitations and exclusions may apply. Contact Ambetter Health or call Member Services at the number on the back of your Member ID Card for answers specific to your coverage.
Not yet a member? Our licensed agents are ready to help you find the perfect plan. Call 855-680-3270 (TTY: 711), Monday-Friday 8 a.m. to 9 p.m. ET, to discuss your health insurance options.