What is the difference between copay and coinsurance?

A copay is a fixed dollar amount you pay for a service (like $30 for a doctor visit), regardless of the total cost. Coinsurance is a percentage of the cost (like 20%), so your payment varies based on the bill. Copays give predictable costs; coinsurance means your cost scales with the service price.

When do I pay a copay vs coinsurance?

Copays usually apply to routine services like doctor visits, urgent care, and prescriptions - often regardless of whether you've met your deductible. Coinsurance typically applies to larger expenses like hospital stays, surgeries, and procedures - usually after you've met your deductible.

Which is better, a plan with copays or coinsurance?

Neither is universally better. Copays provide predictability for routine care, making budgeting easier. Coinsurance can be cheaper for expensive services if your plan has good rates. Many plans combine both: copays for doctor visits and prescriptions, coinsurance for hospital care and procedures.

Copay vs. Coinsurance: What's the Difference?

Q: Do both copays and coinsurance count toward my out-of-pocket maximum?

Yes, both copays and coinsurance payments for covered services count toward your out-of-pocket maximum. Once you reach this limit, your insurance pays 100% of covered care for the rest of the plan year. However, neither typically counts toward your deductible.

The Quick Difference Copay: A fixed dollar amount (e.g., $30) that stays the same regardless of the service cost.

Coinsurance: A percentage of the cost (e.g., 20%) that varies based on how expensive the service is.

Both copays and coinsurance are types of cost-sharing, meaning you and your insurance company split the cost of your healthcare. The key difference is how that cost is calculated.

Side-by-Side Comparison

Copay

$30

Fixed amount. A $30 copay is always $30, whether the visit costs $150 or $300.

Coinsurance (20%)

$30 - $600

Variable amount. 20% of $150 is $30. 20% of $3,000 is $600.

How They Compare

Feature	Copay	Coinsurance
How it's calculated	Fixed dollar amount	Percentage of cost
Example	$30 per visit	20% of bill
Predictability	Highly predictable	Varies by service cost
When it usually applies	Doctor visits, prescriptions, urgent care	Hospital stays, surgery, major procedures
Deductible required first?	Often not (depends on plan)	Usually yes
Counts toward deductible?	Usually no	Yes (it's paid after deductible)
Counts toward out-of-pocket max?	Yes	Yes

Real-World Examples

Scenario 1: Doctor Visit ($200 bill)

With $30 copay: You pay $30. Insurance covers the rest.

With 20% coinsurance (after deductible): You pay $40. Insurance covers $160.

Winner for you: Copay saves $10

Scenario 2: Hospital Stay ($15,000 bill)

With $250 copay per day (3 days): You pay $750.

With 20% coinsurance (after $2,000 deductible): You pay $2,000 + $2,600 = $4,600.

Winner for you: Copay saves $3,850

Scenario 3: Quick Lab Work ($75 bill)

With $30 copay: You pay $30.

With 20% coinsurance (after deductible already met): You pay $15.

Winner for you: Coinsurance saves $15

As you can see, neither is always better. Copays tend to be better for expensive services, while coinsurance can be cheaper for lower-cost services.

When Each Type Typically Applies

Services Usually Using Copays:

Primary care doctor visits
Specialist visits
Urgent care visits
Prescription medications
Mental health visits
Physical therapy sessions

Services Usually Using Coinsurance:

Hospital stays (inpatient)
Surgical procedures
Emergency room visits (some plans)
Diagnostic imaging (MRI, CT)
Lab work
Outpatient procedures
Durable medical equipment

Pro Tip from Us

Many plans combine both. You might pay a $30 copay to see your doctor, but 20% coinsurance if you need an MRI. When comparing plans, look at your Summary of Benefits and Coverage to see which services use copays and which use coinsurance.

Choosing the Right Plan

Consider a Copay-Heavy Plan If:

You see doctors frequently
You prefer predictable, budgetable costs
You take multiple prescription medications
You want to know your cost before each visit

Consider a Coinsurance-Heavy Plan If:

You're generally healthy and rarely need care
You want lower monthly premiums
You have savings to cover a high deductible
You're comfortable with variable costs

How Both Affect Your Out-of-Pocket Maximum

Both copays and coinsurance count toward your out-of-pocket maximum. Once you reach this limit, your insurance pays 100% of covered care for the rest of the year, regardless of whether the service normally has a copay or coinsurance.

This is especially important if you have a major health event. Even if your plan has 30% coinsurance, you'll never pay more than your out-of-pocket maximum.

Need Help Comparing Plans?

Our licensed agents can explain how different copay and coinsurance structures affect your total costs based on your healthcare needs.

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Frequently Asked Questions

Can I have both copays and coinsurance on the same plan?

Yes, most plans use both. You might have copays for routine services (doctor visits, prescriptions) and coinsurance for bigger expenses (hospital stays, procedures). Check your plan's Summary of Benefits to see which applies to each service.

Do copays apply before I meet my deductible?

Often yes. Many plans allow you to pay a copay for doctor visits and prescriptions even if you haven't met your deductible. However, this varies by plan. Some plans require you to meet the deductible before any coverage kicks in (including copays).

If I have 0% coinsurance, do I still pay anything?

With 0% coinsurance, your insurance pays 100% of covered costs after your deductible. You'd still need to pay your deductible first, but once it's met, covered services would be fully paid by insurance.

Why don't all plans just use copays?

Copays work well for predictable, lower-cost services. But for expensive care like hospitalizations, insurers use coinsurance to share the cost more proportionally. Also, plans with all-copay structures tend to have higher premiums.

Copay vs. Coinsurance