A coinsurance cap is the limit placed on coinsurance payments after which the insurer pays the remaining covered costs for a period.
Claims impact
Coinsurance caps are paired with coinsurance percentages and annual limits. They protect insureds from escalating shared-payment risk once thresholds are met.
Underwriting and pricing
Plans with low caps often have lower member burden but may price higher in premiums or narrower provider options.
Scenario
A member has a 20% coinsurance after deductible and a $2,000 annual coinsurance cap. After reaching the cap from prior claims, future claims are paid at 100% within remaining network benefits for the year.