Coinsurance Calculator
Calculate your percentage cost-sharing for surgeries, hospitalizations, and diagnostic procedures after deductible satisfaction, with Out-of-Pocket Maximum cap protection.
Insurance Cost Summary
Coinsurance Calculation Formula
Patient Payment = Deductible Owed + Min(Procedure Balance × Coinsurance %, Out-of-Pocket Max Remaining)- Deductible Portion: Any remaining unmet deductible must be paid first at 100%.
- Coinsurance Split: Standard splits include 80/20, 70/30, or 90/10.
- OOPM Ceiling: Once patient spending reaches the remaining Out-of-Pocket Maximum, coinsurance drops to 0%.
Step-by-Step Worked Example
Calculation Steps:
- Deductible Owed = $0.
- Procedure Balance Subject to Coinsurance = $5,000.
- Calculated Coinsurance = $5,000 × 20% = $1,000.
- Check OOPM Cap: $1,000 is below remaining OOPM of $2,500.
- Patient Responsibility = $1,000.
- Insurance Pays = $5,000 - $1,000 = $4,000.
How to Use This Calculator
- 1Enter the contractual allowed cost of your medical procedure.
- 2Indicate whether your annual deductible has already been met.
- 3Enter your coinsurance percentage rate (e.g. 20%).
- 4Input the remaining balance on your plan Out-of-Pocket Maximum.
Assumptions & Limitations
- Procedure must be a covered benefit performed by an in-network medical provider.
Frequently Asked Questions
What does 80/20 coinsurance mean?
80/20 coinsurance means your health insurance carrier pays 80% of covered in-network medical bills after you meet your deductible, and you are responsible for the remaining 20%.
Can coinsurance exceed my plan maximum?
No. Federal law prohibits qualified health plans from charging coinsurance after you reach your annual in-network Out-of-Pocket Maximum.
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