Yes. In most U.S. health insurance plans, you continue to pay coinsurance after your deductible is met until you reach your out-of-pocket maximum. After that limit is reached, the plan typically pays 100% of covered services for the rest of the plan year.
Understanding the Core Terms
What Is a Deductible?
A deductible is the fixed amount you must pay for covered healthcare services before your insurance plan starts sharing costs. Deductibles reset each plan year.
What Is Coinsurance?
Coinsurance is the percentage of costs you pay for covered services after meeting your deductible. Common splits include 20% patient / 80% insurer or 30% / 70%.
What Is an Out-of-Pocket Maximum?
The out-of-pocket maximum is the most you will pay in a plan year for covered services. It includes deductibles, coinsurance, and copayments for in-network care.
Do You Pay Coinsurance After Deductible Met?
Standard Rule in U.S. Health Plans
After your deductible is met:
- Insurance begins paying its share.
- You pay coinsurance on covered services.
- This continues until the out-of-pocket maximum is reached.
This structure applies to:
- Employer-sponsored health plans
- Marketplace (ACA) plans
- Many private individual policies
How the Payment Flow Works (Step-by-Step)
Step 1: Before Deductible
You pay 100% of allowed costs (except preventive services).
Step 2: After Deductible
You pay coinsurance (for example, 20%).
Insurance pays the remaining percentage.
Step 3: After Out-of-Pocket Maximum
Insurance pays 100% of covered, in-network services.
Real-World Cost Example
Plan Details
- Deductible: $2,000
- Coinsurance: 20%
- Out-of-pocket max: $6,000
Scenario
- You incur $10,000 in covered medical bills.
Breakdown
- First $2,000: paid by you (deductible)
- Next $20,000? No—only until OOP max:
- You pay 20% until your total spending hits $6,000
- Insurance covers the rest
Services That May Not Require Deductible or Coinsurance
Preventive Care
Under ACA rules, many preventive services are covered at 100%:
- Annual physicals
- Vaccinations
- Cancer screenings
Copay-Only Services
Some plans allow copays instead of coinsurance for:
- Primary care visits
- Generic prescriptions
These rules vary by plan design.
In-Network vs Out-of-Network Impact
In-Network Care
- Deductible and coinsurance apply normally.
- Counts toward out-of-pocket maximum.
Out-of-Network Care
- Higher coinsurance rates.
- Separate or no out-of-pocket maximum.
- Balance billing may apply.
Medicare and Coinsurance Differences
Medicare Part A
Coinsurance applies after deductible for hospital stays.
Medicare Part B
- Annual deductible applies.
- After deductible, patient typically pays 20% coinsurance.
- No out-of-pocket maximum unless supplemental coverage exists.
High-Deductible Health Plans (HDHPs)
Special Considerations
HDHPs often have:
- Higher deductibles
- Lower monthly premiums
- Coinsurance after deductible
- Eligibility for Health Savings Accounts (HSAs)
Coinsurance still applies until the out-of-pocket maximum is reached.
Unique Clinical Takeaways
1. Chronic Disease Patients Face Predictable Coinsurance Burden
Patients with chronic kidney disease, diabetes, or cancer often meet deductibles early in the year. Coinsurance becomes the dominant cost driver, affecting medication adherence and follow-up compliance.
Actionable Insight: Patients should request annual cost-of-care estimates to plan HSA or FSA contributions.
2. Coinsurance Can Alter Care-Seeking Behavior
Higher coinsurance rates are associated with delayed diagnostics and skipped specialist visits, especially among middle-income patients who do not qualify for subsidies.
Actionable Insight: Clinicians should proactively discuss cost transparency during care planning to reduce deferred treatment risk.
3. Facility-Based Billing Increases Coinsurance Exposure
Hospital outpatient departments often bill at higher allowed amounts than physician offices. Coinsurance percentages apply to these higher rates, increasing patient liability.
Actionable Insight: When clinically appropriate, patients should ask whether procedures can be safely performed in lower-cost outpatient settings.
Common Patient Questions
Does Coinsurance Apply to Emergency Care?
Yes. Emergency services are usually subject to coinsurance after the deductible, even if obtained out-of-network, though ACA protections limit cost-sharing.
Does Prescription Drug Coinsurance Count?
Yes, if the plan uses coinsurance instead of copays for certain tiers, these costs count toward the out-of-pocket maximum.
Does Family Coverage Change the Rule?
Family plans may have:
- Individual deductibles
- Family deductibles
- Combined out-of-pocket limits
Coinsurance rules still apply after each deductible is met.
How to Check Your Plan’s Exact Rules
- Review the Summary of Benefits and Coverage (SBC)
- Check your insurer’s member portal
- Contact customer service for written confirmation
Key Takeaway Summary
- Meeting your deductible does not end cost-sharing.
- Coinsurance applies until your out-of-pocket maximum is reached.
- Preventive services are usually exempt.
- Plan design, network status, and care setting significantly affect costs.