Quick Answer: In-network coinsurance is the percentage of a negotiated, discounted charge you pay after your deductible when using a plan-contracted provider. Out-of-network coinsurance is the higher percentage you pay on full, undiscounted charges. Typical in-network rates: Bronze 40%, Silver 30%, Gold 20%, Platinum 10%. HMOs and EPOs cover no out-of-network care except emergencies, and the No Surprises Act (2022) limits surprise balance billing for ER visits and ancillary services at in-network facilities.
Annual In-Network vs. Out-of-Network Coinsurance Limits
Current annual limits| Metal Tier | Typical In-Network Coinsurance | Typical Out-of-Network Coinsurance |
|---|
| Bronze | 40% | 50% (if covered) |
| Silver | 30% | 40% (if covered) |
| Gold | 20% | 30% (if covered) |
| Platinum | 10% | 20% (if covered) |
HMO and EPO plans do not cover out-of-network care except emergencies. PPO and POS plans cover it at the higher rates shown. Always check your Summary of Benefits and Coverage for your exact rate.
Source: ACA metal tier actuarial value standards; CMS plan data 2026
Why the Underlying Charge Matters as Much as the Percentage
In-network providers have contracts that set discounted rates with your insurer, so your 20% coinsurance applies to a negotiated amount that may be 40 to 60 percent below the list price. Out-of-network providers have no such contract. Your plan pays a reference amount and you owe your coinsurance percentage on top of that, plus any balance billing the provider adds above it. The No Surprises Act (2022) bans balance billing for ER care and ancillary providers at in-network facilities, but does not protect you when you knowingly schedule care with an out-of-network provider. See the out-of-pocket maximum glossary entry to understand the 2026 cap of $10,600 individual. For a real-world example of how in-network vs out-of-network coinsurance adds up, see the echocardiogram cost guide or colonoscopy cost guide.
- HMO / EPO plans: out-of-network coverage is 0% except emergencies. You pay the full bill.
- PPO / POS plans: out-of-network coinsurance applies, but on undiscounted charges and balance billing may add more.
- 2026 ACA in-network OOP max: $10,600 individual / $21,200 family. Out-of-network costs often count toward a separate, higher cap or no cap at all.
Frequently Asked Questions
What is the typical in-network coinsurance on an ACA marketplace plan?
It depends on the metal tier. Bronze plans typically charge 40% coinsurance after the deductible, Silver 30%, Gold 20%, and Platinum 10%. These are averages; individual plans vary. Check your Summary of Benefits and Coverage for the exact rate.
Does my plan cover out-of-network care at all?
It depends on your plan type. HMO and EPO plans do not cover out-of-network care except in a medical emergency. PPO and POS plans do cover out-of-network providers, at a higher coinsurance rate, typically 10 to 20 percentage points above your in-network rate, applied to undiscounted charges.
What is balance billing, and does the No Surprises Act protect me?
Balance billing is when an out-of-network provider charges you the gap between their full bill and what your plan pays. The No Surprises Act (effective January 1, 2022) protects you from surprise balance bills for emergency services and ancillary providers at in-network facilities. It does not cover scheduled out-of-network care you chose.
Do out-of-network costs count toward my out-of-pocket maximum?
Often no, or only partially. Most plans track in-network and out-of-network spending toward separate out-of-pocket maximums. The 2026 ACA in-network OOP max is $10,600 individual. Out-of-network caps are frequently higher, and some plans have no out-of-network cap at all. Check your plan documents.
