Co-Insurance or Co-pay

This is the percentage or amount of expenses that the insured pays (if any) after the deductible is paid. Example: 'Co-Insurance = 20% or co-pay is 80/20' means that the insurance company pays 80% of the charges, the insured pays 20%. Often there is a maximum co-pay amount, i.e., a limit or ceiling above which the insurance provider pays 100%. Example: 'Deductible = $250 and 80/20 co-pay up to $5000, then 100% up to policy maximum.' This means the insured is required to pay the deductible of $250 plus 20% of expenses up to $5,000, and the insurance provider pays 100% of covered expenses that exceed $5000 up to the maximum policy coverage limit. Thus, if total expenses exceed $5000 (e.g. $20,000 in total medical expenses) then the insured pays $250 (deductible) plus the co-pay maximum of $1000 (20% of the first $5000) for a total out of pocket cost to the insured of $1250, and the insurer pays the remaining $18,750 of expenses. Where total expenses are only $3000, then the insured pays $250 (deductible) plus $600 co-pay (20% of $3000) for a total out of pocket cost of $850, and the insurer pays the remaining $2150 of expenses

See Also: Emergency Benefits; Exclusions; Expenses; Family Plans;

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