Coinsurance

Coinsurance is the percentage of the cost of a covered health service that you pay after meeting your deductible. The rest is paid by your insurance plan.

A typical Silver plan might have 30% coinsurance after the deductible — meaning you pay 30% of the bill and the plan pays 70%.

Example

You have a $3,000 deductible and 30% coinsurance.

• You have surgery that costs $10,000.
• First, you pay your $3,000 deductible.
• Then coinsurance kicks in on the remaining $7,000. You pay 30% = $2,100.
• The plan pays 70% = $4,900.
• Your total out-of-pocket for the surgery: $5,100 ($3,000 deductible + $2,100 coinsurance).
• This counts toward your out-of-pocket maximum.

Coinsurance vs. copays

• Copay = fixed dollar amount ($30 per visit)
• Coinsurance = percentage (20% or 30% of the bill)

Marketplace plans typically use copays for routine care (primary care, specialist, generics) and coinsurance for high-cost services (surgery, hospital stays, MRIs).

Coinsurance by metal tier (typical for 2026)

• Bronze: 40% (you pay 40%, plan pays 60%)
• Silver: 30% (or less with CSR)
• Gold: 20%
• Platinum: 10%

This is the actuarial value of the tier expressed from your perspective.

Coinsurance counts toward the out-of-pocket maximum

Every dollar of coinsurance you pay during the year counts toward your out-of-pocket maximum. Once you hit it, the plan pays 100% of covered services for the rest of the year.

Out-of-network coinsurance

Many plans charge much higher coinsurance for out-of-network providers — often 50% or higher, and the out-of-network amounts may not count toward your in-network out-of-pocket maximum. Always verify network status before scheduling care.

Related terms

• Deductible
• Copay
• Out-of-Pocket Maximum
• Premium

Get a free plan comparison — a licensed agent can break down coinsurance, copays, and deductibles plan by plan.