Coinsurance 101

Generally speaking, coinsurance is a percentage you pay for medical services or prescription medications. A few points on coinsurance:

• Coinsurance does not apply to medical, urgent care or ER visits ­that have a fixed dollar copayment. Rather, it applies to medical services. Example: a doctor’s appointment (copay) vs. an X-ray (coinsurance) you might get during that appointment.
• Coinsurance doesn’t count toward your deductible, but it does count toward your total out-of-pocket maximum for the year.

Coinsurance works differently depending on your plan. Let’s break it down.

ABC

Medical:
With ABC plans, coinsurance is a percentage you pay for medical services after the applicable deductible is met. Depending on your plan, you’ll pay 0%, 10% or 20% coinsurance.

Prescriptions:
With ABC plans, you pay the full cost of prescriptions, except for certain preventive prescriptions, until the deductible is met. Once you meet your deductible, you’ll pay prescription copays or coinsurance on prescriptions until you reach your total out-of-pocket maximum.

Balance+

Medical:
With Balance+, you pay 20% coinsurance for medical services that don’t have a copay after you meet your deductible.

Prescriptions:
With Balance+, you pay the full cost of prescriptions, except for certain preventive prescriptions, until your deductible is met. After your deductible is met, you are responsible for copays or coinsurance until you reach your total out-of-pocket maximum.

Choices

Medical:
With Choices, coinsurance is a percentage you pay for medical services that don’t have a copay after you meet your deductible. Coinsurance is 0%, 10% or 20%, depending on the plan you choose.

Prescriptions:
With Choices, you pay either copayments or coinsurance for prescriptions, except for certain preventive prescriptions, depending on the details of the Rx plan you choose.

Essentials by MESSA

Medical:
With Essentials by MESSA, you pay 20% coinsurance for medical services that don’t have a copay after you meet your deductible.

Prescriptions:
With Essentials by MESSA, you are responsible for copays or coinsurance, except for certain preventive prescriptions, until you reach your total out-of-pocket maximum.

If you have any questions, call our Member Service Center at 800-336-0013. You can also connect via live through your MyMESSA account or the MESSA app. We’re happy to help!