Ask a Zenefits Advisor: What are Average Coinsurance Costs for California and Texas?

Bud Bowlin has been advising business owners about health insurance and benefits for more than 35 years. For his 70th birthday, we gave him his own advice column. Got a burning benefits question for Bud? Send it to [email protected].

Hey Bud,

We are currently reviewing insurance plans for our open enrollment. On a few of the quotes, the copays for office visits, specialists, emergency room and urgent care visits are listed as a percentage of the cost of the appointment. Is there an average cost of these four types of visits in CA and TX—so I can better gauge what this would mean financially for our team?

Yikes! Ambiguous Summary Makes Estimating Expenditures Nebulous

Dear Y.A.S.M.E.E.N.,

Much like siblings, copays and coinsurance look alike, but behave differently. I did a column explaining the Summary of Benefits and Coverage (SBC), and your question gives me the opportunity to get into more detail on these two important health insurance terms. Office visits, specialist visits, emergency room visits, and urgent care visits can be expressed as either a fixed copay or as a coinsurance percentage. It sounds like you’re seeing coinsurance on your quotes, but just in case, we’ll tackle both. This way, I can share some information on the terminology and also give you an idea of rates for California and Texas.

Copays are a fixed dollar amount that you pay for a specific procedure or benefit. For example, an office visit to a general practitioner may be listed on your SBC as a $40 copay. Once you pay the $40 copay, the insurance carrier pays 100% of the balance for that appointment. When you see copays on your SBC, you know exactly, in advance, what you’re going to pay for a service.

Coinsurance, on the other hand, is a variable percentage you pay for (usually) less common procedures or benefits. Coinsurance kicks in after you’ve met your deductible. Then, you and the carrier split the total cost per the percentage on your SBC. A common coinsurance split is 80% paid by the carrier and 20% paid by you, the insured.

The cost of an office visit in Texas varies between $50 and $250, depending on the diagnosis and services performed. California averages slightly higher in the $70 to $300 range. If your SBC indicates a $30 copay for an office visit, then that’s your total obligation for that visit—regardless of the total actual cost. If your SBC indicates a coinsurance percentage for office visits, then you split the entire actual cost by the percentages specified. For instance, if the doctor charges $100, and the coinsurance split is 80/20, you’re responsible for $20.

Specialist visits can have an even greater variance based upon the provider’s specialty, the seriousness of the diagnosis and the duration of the appointment. In Texas, the averages are $90 to $400, and in California they’re $120 to $500. It’s common for a specialist to charge double an office visit. So, you may see plans with a $30 office visit copay and a $60 specialist visit copay. Or, in the case of coinsurance, your cost to see a specialist would be double the percentage of an office visit.

A few words of explanation on Emergency Room (ER) and urgent care visits. When you see an emergency room visit copay or coinsurance on your SBC, the insurance carrier is typically referring to a hospital-based ER that provides high-level care for life-threatening situations. Urgent Care Centers are not usually hospital-based. They can be located in shopping centers or office buildings, and are used for injuries or illnesses with sudden onsets at times (like nights and weekends) when regular providers are unavailable.

Due to the disparity in costs, I recommend only using the ER for life-threatening situations. ER copays in Texas range from $150 to $300, while ER copays in California range from $200 to $500. Comparatively, urgent care copays range from $40 to $100 in both Texas and California. Coinsurance for ER and urgent care visits varies according to your plan, but be aware that the deductible must typically be met before coinsurance is applied.

Yasmeen, I hope this helps. As you continue your selection process, keep in mind:

A copay is a fixed dollar amount, after which the insured has no further obligation and the deductible is not considered.
Coinsurance is a percentage and usually the insured will be out more money versus benefits that have copays.
Overall, California health costs are slightly higher than Texas health costs.
Only use Emergency Rooms for life-threatening situations!

Thanks again for submitting your question. My inbox is always open.