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Coinsurance

Coinsurance -sometimes called the reimbursement rate - is the percentage of eligible health or dental expenses your plan will pay after any deductible. It’s the insurer’s share of the bill, with the remainder paid by you. Typical plans cover 70–100% of eligible costs; the rest is your out-of-pocket portion.

How It Works

Coinsurance is usually written as a percentage, so an 80 percent coinsurance means your plan covers 80 percent of the covered amount of an eligible expense and you pay the remaining 20 percent out-of-pocket. It applies only after you have satisfied your deductible, the set amount you must pay out of pocket before your plan coverage kicks in if your plan has one, and unlike that deductible it then applies to every eligible expense after the deductible is met. Before the percentage is calculated, plans may first limit the eligible expense to a reasonable and customary charge or to a provincial dental association fee guide. Coinsurance is one of the ways benefit plans share healthcare costs between the insurer and the insured, which helps keep group plan premiums more affordable and encourages responsible use of services. As a rule, a higher coinsurance percentage paid by the plan generally comes with more comprehensive coverage and means you pay less out-of-pocket.

Example:

Suppose your Canadian health and dental plan reimburses physiotherapy at 80 percent coinsurance and you have already met your annual deductible. When you visit the physiotherapist for an eligible visit, your plan pays 80 percent of the eligible cost and you cover the remaining 20 percent out-of-pocket. If your plan instead covers major dental work at only 50 percent, you would pay half of that eligible cost yourself, which shows how coinsurance can differ by benefit category within the same plan.

What to Watch For:

Do not assume one coinsurance percentage applies across your whole plan. Coinsurance percentages can differ for certain benefits, such as major dental work or orthodontics, rather than being uniform across the whole plan, and coinsurance can also vary by employee group. It is common, for instance, for a Canadian benefits plan to have 100 percent coinsurance for basic dental but only 50 percent for major restorative dental. Remember too that plans may limit eligible expenses to a reasonable and customary charge or to a provincial dental association fee guide, and these limits are applied to the claim before the coinsurance percentage is calculated.

Related Terms

Coverage / Benefit

Coverage, sometimes referred to as a benefit, is the range of health or dental services, supplies, or treatments that your insurance plan agrees to pay for under its terms and conditions. Each benefit represents a category of care, such as prescription drugs, dental services, vision care, or paramedical treatments.

Extended Health Care Insurance

Extended health care insurance (EHC) is supplemental coverage that helps pay for medical expenses not covered by your provincial or territorial health plan. It protects you from out-of-pocket costs associated with services such as prescription drugs, vision care, medical equipment, hospital upgrades, emergency travel medical care, and paramedical services like physiotherapy or chiropractic treatments.

Pay-Direct card / Drug card

A pay-direct card, also known as a drug card, is a plastic or digital card issued by your health insurance provider that allows pharmacies to bill your insurer directly for eligible prescription drugs. Instead of paying the full cost upfront and submitting a claim later, you pay only your portion - such as a deductible or coinsurance - at the point of sale.

Benefit

A benefit is the specific financial protection or coverage provided under an insurance policy. In health and dental insurance, a benefit refers to the payment or reimbursement made by the insurer for eligible medical, dental, or wellness expenses. Each benefit category - such as prescription drugs, dental services, vision care, or physiotherapy - outlines what is covered, how much the insurer will pay, and any applicable limits or conditions.

Health Insurance

Health insurance is a type of coverage that helps pay for medical and healthcare expenses not fully covered by Canada’s public health system. It protects individuals and families from the high cost of prescription drugs, medical services, and treatments that fall outside provincial or territorial government health plans. Health insurance can be obtained through an employer’s group benefits plan or purchased individually from a private insurer.

Relevant Plans

Plans that relate to Coinsurance

Alberta Blue Cross - Blue Assured - Basic

Alberta Blue Cross - Blue Assured - Basic

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced

Alberta Blue Cross - Blue Assured - Enhanced

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced+

Alberta Blue Cross - Blue Assured - Enhanced+

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Premium

Alberta Blue Cross - Blue Assured - Premium

Can apply at anytime, at any age.

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