Coinsurance Copay Deductible



Co-insurance is the amount for which the patient is responsible after the deductible or co-payment and the carrier’s payment are applied. To boost revenue in an office, there should be a written policy—for both staff and patients to read and understand—explaining when and how co-pays, deductibles, and co-insurance will be collected. Coinsurance refers to the percentage of treatment costs that you have to bear after paying the deductibles. This amount is generally offered as a fixed percentage. It is similar to the copayment provision under health insurance. Copayments/Coinsurance Most members' health coverage includes a copayment, a deductible amount, and/or coinsurance. Using the HNS Verification of Benefits Form, be sure to verify the specific amount of the member's copayment and/or deductible/coinsurance prior to providing any services to the member.

For Active Employees and non-Medicare Retirees Effective July 1, 2020

Please note: There are some exceptions to the tables below; please see the Benefits Summary (MS Word) for a more complete explanation of medical coverage.

Coinsurance Copay Deductible

Medical Coverage

PremiumCoinsurance Copay Deductible
Type of Visit or TestCopay Amount
Office visit with a primary care doctor who participates in the Anthem network$20
Office visit with a specialist who participates in the Anthem network$40
Visit to a participating walk-in clinic (PDF)$25
Visit to an emergency room (copay is waived if admitted to in-patient status)$300
  • Office visit copay is waived for preventive visits
  • No referral required by the insurance plan for visits to specialist or walk-in clinic

Coinsurance Copay And Deductible

Out-of-Pocket ExpenseIndividualFamily
In-NetworkOut-of-NetworkIn-NetworkOut-of-Network
Calendar year deductible$600$3,000$1,200$6,000
Coinsurance rate - participating provider10%40%10%40%
Annual maximum out-of-pocket expense
(deductible + coinsurance + medical copay)
$2,000$5,000$4,000$10,000

What Does Copay With Deductible Mean

Prescription Coverage

Coinsurance Copay Deductible

Deductible And Coinsurance Explained

Medication CategoryUp to 30-Day Supply
Copay Amount Per Prescription
Up to 90-Day Supply
Copay Amount Per Prescription
Generics$10$15
Preferred brand-name$30$45
Non-preferred brand name$45$70
Specialty25% coinsurance up to $15025% coinsurance up to $225
Lifestyle$50$75

Copay Coinsurance Deductible Definition

State of Maine Statute: Title 5 285, 285-A and 286