Back to all terms

Reimbursement / Coinsurance

Reimbursement is the amount an insurance company pays back to the insured person or directly to a healthcare provider for eligible expenses covered under a policy. Coinsurance is the portion of the cost that the insurer agrees to pay, expressed as a percentage, with the remaining balance paid by the insured. Together, these terms describe how healthcare costs are shared between you and your insurer once a claim is approved.

How It Works

Coinsurance is the percentage of an eligible healthcare expense that you pay out of pocket, while your plan covers the rest, and it is a cost-sharing arrangement that only applies after you have satisfied any deductible your plan may have. A common arrangement is 80 percent coinsurance, meaning the plan covers 80 percent of the covered amount and you pay the remaining 20 percent. Unlike a co-pay, which is a fixed amount per service, the coinsurance amount varies with the cost of each claim. Coinsurance percentages can differ by benefit category, so a Canadian plan may list separate coverage levels for drugs, dental, vision, and paramedical services. In group benefit plans it is common to set different coinsurance for different benefits, such as full coverage for basic dental but only half for major restorative dental. Reimbursement may then occur automatically through direct billing or manually when you submit a claim with receipts and documentation, with each claim assessed against eligibility, remaining maximums, coinsurance, and deductibles.

Example:

Imagine a Canadian extended health plan that reimburses physiotherapy at 80 percent coinsurance once the annual deductible has been met. When you visit a physiotherapist, the insurer first checks the eligible expense against its reasonable and customary limit, then pays its 80 percent share and leaves the remaining 20 percent as your out-of-pocket portion, which you pay directly to the clinic.

What to Watch For:

Plans may limit the eligible expense before applying coinsurance, often based on the reasonable and customary charge or a provincial dental association fee guide, and that limit is applied to the claim before the coinsurance percentage. Because coinsurance only kicks in after any deductible is satisfied and the amount you pay varies with each claim, it helps to know your plan's deductible and how each benefit is treated. Review the coinsurance percentages for each benefit category, since drugs, dental, vision, and paramedical services can carry different coverage levels, and a single plan may pay full coverage for basic dental but only half for major restorative work.

Related Terms

Claim

A claim is a formal request you or your healthcare provider submit to your insurance company to receive reimbursement or direct payment for eligible medical or dental expenses covered under your plan. Submitting a claim provides the insurer with the necessary information - such as receipts, treatment details, and provider information - to verify the service and determine the amount payable according to your policy’s terms.

Insurer

An insurer is the insurance company or organization that provides financial protection to individuals or groups in exchange for premium payments. The insurer assumes the risk of potential loss and agrees to pay benefits for covered claims according to the terms of the policy. Insurers evaluate applications, determine premiums, issue policies, and manage claims through underwriting and administration processes.

Claim Submission Deadline

The claim submission deadline is the final date by which an insured person must submit a claim to their insurance company for reimbursement of eligible expenses. After this date, the insurer is not obligated to pay the claim, even if the expense itself would have been covered. This deadline ensures timely processing, accurate recordkeeping, and proper financial reporting for both the insurer and the policyholder.

Provider

A provider is a licensed healthcare professional, facility, or service organization that delivers medical, dental, vision, or paramedical care to patients. In the context of insurance, a provider is any individual or entity authorized to perform covered services and submit claims for reimbursement to an insurer. Providers include physicians, dentists, pharmacists, physiotherapists, chiropractors, optometrists, hospitals, and clinics.

Prior Authorization

Prior authorization is the process through which an insurer reviews and approves certain medical treatments, procedures, or prescription drugs before they are performed or dispensed. It ensures that the recommended care is medically necessary, appropriate, and covered under the policy before expenses are incurred. Prior authorization helps manage costs and ensures the use of safe, evidence-based treatments that align with clinical guidelines.

Relevant Plans

Plans that relate to Reimbursement / 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.

Have questions about your insurance coverage?

Our licensed advisors can help you understand your options and find the right plan for your needs.

Contact Us