We define common health coverage terms on our websites and in our materials. But technical definitions may not always fully explain some concepts.

Each article in our What Does It All Mean series looks at a few health care benefit terms in more depth. This month we look at two more terms that can be key to getting the top value from your benefits.

Coinsurance

The Official Definition

A percentage of a covered service that you are responsible for paying or the percentage paid by your plan.

Let’s Break That Down

This is not a set dollar amount. Instead, it is a portion of covered charges. The portion could be just a tenth (10 percent) or a fifth (20 percent), or sometimes it may be higher. Check your benefit book to confirm what percentages you pay for various benefits.

Example

You find out you need to have a few minor procedures done. Your coinsurance is 10 percent. One of the procedures costs $5,000. You pay $500. Your second procedure is $500. Your coinsurance for that one is $50.

Coinsurance Tip

If you pay coinsurance for a service, it benefits you to find lower cost options. Check Provider Finder® to compare costs among providers in your network. Whatever your portion is, it will be a portion of a smaller amount when you select a lower cost provider. Ten percent of $1,000 is a lot less than 10 percent of $2,500. You can access Provider Finder to check costs by logging in to Blue Access for MembersSM and clicking on the Find a Doctor or Hospital tab.

Copayment

The Official Definition

A fixed dollar amount you are required to pay for covered services at the time you receive care.

Let’s Break That Down

This is what you usually pay out of pocket for doctor visits or prescription drugs. Some benefit plans apply a $30 copay for office visits. Under this plan, you would pay $30 each time you see your PCP unless you have met your out-of-pocket maximum for the year.

Example

You catch strep throat from a coworker, and you see your doctor to get tested. You pay the office visit copay under your plan ($30 for example). Then you go to the pharmacy to pick up your antibiotic, which will also have a copay. Depending on your plan, the copay for the prescription might be $10.

Copayment Tip

As children get older, some doctors are OK with them coming to simple visits on their own. Remember to give your responsible child the means to pay the copay when he or she visits the doctor.

More terms and their definitions are available on our website.