Coinsurance Explained [Changes from 2019-2020 Sharp Benefits]


If you have the Sharp Select plan, you might have noticed that some of your benefits changed this year 

Sharp Select and Sharp Saver both now offer a coinsurance model for hospital procedures. Sharp Select has a 15% coinsurance on outpatient procedures (procedures that do not require overnight stay in the hospital), while Sharp Saver has a 30% coinsurance on both inpatient (procedures that require overnight stay in the hospital) and outpatient procedures. Here’s the explanation of benefits for Sharp Select and Sharp Saver 


What’s the difference between Coinsurance and Copay? 

Copay is a flat rate that is agreed upon between you and your insurance when you enroll for benefits. The rate is fixed, meaning no matter what, you’ll only pay the dollar amount listed on your explanation of benefits.  

Coinsurance, on the other hand, takes the cost of the procedure into account. A 15% coinsurance means you’ll pay 15% of whatever the costs of the procedure are. Meaning, if you get surgery that costs $10,000, you will only pay $1,500 and your insurance will cover the rest. 

Both coinsurance and copay are factored into your “out-of-pocket-maximum" which is the most you’ll ever have to spend on health care covered by Sharp in a given benefit year. 


Say someone has been to the doctor several times this year and has already spent $2500 on copay and coinsurance. A medical event causes them to go to the hospital for outpatient surgery and the surgery costs $10,000.  

If they have the Sharp Select plan, their coinsurance for this procedure is 15% and their out-of-pocket-maximum is $3,000. Meaning, they would only end up paying $500 for this surgery, because the cost of the surgery would cause them to reach their out-of-pocket-maximum. If they required additional procedures or doctor visits that would normally be covered by Sharp, they would pay $0 until the next benefit year.  

Sharp Rates affected by Coinsurance 


Sharp Select 

Sharp Saver 

Outpatient Fees 

15% Coinsurance 

30% Coinsurance 

Inpatient Fees  

$500 Copay 

30% Coinsurance 


Other Notes 

Remember coinsurance also only kicks in AFTER your deductible is paid if you have the Sharp Saver plan. Meaning, you’re responsible for the first $1,000 in medical expenses.  

You can only enroll in Sharp Healthcare during open enrollment, in the first 30 days of being hired/promoted, or within 30 days of a QLE (Qualifying Life Event: basically big moments in your life, like: when something changes your insurance status, you have a child, or retire). 

Coinsurance can also represent the percent your insurer pays rather than the percent you pay, which is the case with the MetLife Dental PPO plan. Pay close attention to your explanation of benefits so you know the amount you're covered for. 

Details and figures used in this article reflect the 2020-2021 Benefit Year.


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