What is a Medical Co-Insurance?

The easiest way to remember about Co-insurance is that it is a percentage of costs of a covered healthcare service you pay (for example 20%) after you've paid your deductible. So, typically the coinsurance is a percentage.  

What is a Medical Co-Payment?

Well, if you have a health insurance plan you also have to pay a small amount called co-pay when you see a doctor, pick up medication etc. (For example $20-$40 office visit; or $15-$30 for a lab test, etc - depending on the plan). For specifics, please refer to your health plan summary of benefits. 

What is a Medical Deductible?

If you understand how the deductible works you can save so much money on your health insurance premiums… So, what is a medical deductible anyways? By definition a deductible is the amount you pay for covered health care services before your insurance plan starts to pay. In this video, we explain what the deductible is and how it works. 

Health Insurance Frequently Asked Questions -health insuranc

Q. What is covered by health insurance plans in 2020?

If you are shopping for health insurance in California for year 2019, this presentation will help you see side by side comparison of various health plans and possibly help you decide what plan would work best for you and your family.  Confused and have questions about: penalty for 2019, open enrollment to buy health insurance, deductible, copays, coinsurance, bronze, silver, gold and platinum plans, blue shield, Kaiser, VHP, Valley Health Plan, Anthem Blue Cross, United Healthcare, HealthNet, Oscar, Sutter Health, Delta Dental, dental and vision insurance etc. we can help answer all these questions!

When is the Open Enrollment for 2020?

 When is the open enrollment to buy health insurance? what are the health insurance changes in 2020? Do you have other questions about health insurance? On this site, you can find answers to f.a.q health insurance questions.     

The open enrollment is October 15, 2019 - January 15, 2020.      

 The sign-up process beginning October 15 and continuing through December 15 for a January 1, 2020 effective date. Consumers signing up between December 16 and January 15 will have a February 1, 2020 effective date. Covered California’s exchange will "go live" for active renewals on October 8, 2019. 

What is SEP- Special Enrollment Period?

 SEP is the special enrollment period- it allows anyone to apply for health insurance outside of the open enrollment. Here are the SEP reasons: 

- Lost or will soon lose my health insurance

- Permanently moved to/within California

- Had a baby or adopted a child

- Got married or entered into domestic partnership

- Returned from active duty military service  

- Gained citizenship/lawful presence

 - Member of a Federally Recognized American Indian or Alaska Native Tribe

How can I find a Certified Insurance Agent to help me with CoveredCA?

It is quite easy. You can find an agent by searching "Find Help Near You" on CoveredCa web-site. For example, you can search for Diana Polyakov, a Certified Insurance Agent, provide your zip code (make sure to increase the search distance). Certified Insurance Agents are trained to be fair, accurate and impartial when representing Covered California plans to consumers. Agents can never charge handling, set-up or consultation fees to assist consumers with their Covered California enrollment.  

How to correct information on form 1095-A?

 Here is the form that you will have to file to correct or dispute information on form 1095-A- Dispute Form 1095-A for Covered California Consumer 

What is the health insurance subsidy / tax credit?

The subsidy or the tax credit is the amount that you receive (not directly), which helps you pay for health insurance. The subsidy depends on the income (your adjusted gross income), family size and your zip code. Here is the income table for the year 2020

coveredca 2020 subsidy penalty income limits qualify for low insurance medical medi-cal medicaid hmo


Learn about your health insurance plans


What is a Deductible?  

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. 

*Please note NOT ALL procedures are subject to the deductible, so check your summary of benefits. 
         Many plans pay for certain services, like a checkup or disease management programs, before you've met your deductible. 

  • After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
  • Some plans have separate deductibles for certain services, like prescription drugs.
  • Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members
  • Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.

 What is Co-Insurance? 

Co-insurance is the percentage of costs of a covered healthcare service you pay (for example 20%) after you've paid your deductible. Typically the coinsurance is a percentage. 

For example: 

Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.

If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
If you haven't met your deductible: You pay the full allowed amount, $100.

Example of coinsurance with high medical costs

Let's say the following amounts apply to your plan and you need a lot of treatment for a serious condition. Allowable costs are $12,000.

Deductible: $3,000
Coinsurance: 20%
Out-of-pocket maximum: $6,850

You'd pay all of the first $3,000 (your deductible).

You'll pay 20% of the remaining $9,000, or $1,800 (your coinsurance).

So your total out-of-pocket costs would be $4,800 — your $3,000 deductible plus your $1,800 coinsurance.

If your total out-of-pocket costs reach $6,850, you'd pay only that amount, including your deductible and coinsurance. The insurance company would pay for all covered services for the rest of your plan year.

Generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance. 


What is a Co-payment?

A fixed amount (for example $20) you pay for a covered health care service after you've paid your deductible. Generallyit s a fixed dollar amount. 

For example:
Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.

If you've paid your deductible: You pay $20, usually at the time of the visit.
If you haven't met your deductible: You pay $100, the full allowable amount for the visit.

  • Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
  • Generally, plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.


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