Coinsurance vs. Copay:
Coinsurance and copays are important concepts to help you understand the costs of health insurance. These and other out-of-pocket costs affect how much you’ll pay for the healthcare you and your family receive.
KEY TAKEAWAYS
- A copay is a set rate you pay for prescriptions, doctor visits, and other types of care.
- Coinsurance is the percentage of costs you pay after you’ve met your deductible.
- A deductible is the set amount you pay for medical services and prescriptions before your coinsurance kicks in fully.
- After you have spent the out-of-pocket maximum, your healthcare plan should cover 100% of eligible expenses.
- Generally, the lower your monthly premiums, the more out-of-pocket expenses you must pay before insurance begins to cover your bills.
What Is a Deductible?
First, to understand the difference between coinsurance and copays in healthcare insurance, it helps to know about deductibles.
A deductible is a set amount you pay each year for your healthcare before your plan starts to share the costs of covered services. For example, if you have a $3,000 deductible, you have to pay the initial $3,000 of health care costs before your insurance kicks in and starts sharing the costs with you.
If you have any dependents on your policy, you’ll have an individual deductible and a different (higher) amount for the entire family. Say your policy has a $5,000 individual deductible and a $10,000 deductible. So if you have a procedure that costs $6,000, your individual deductible kicks in at $5,000 and $6,000 is credited towards your family deductible. Later, if your daughter has a procedure that costs $4,500, the family deductible now totals $10,500. Thus, her deductible applies to the last $500 of her bill, as the $10,000 family deductible has been met. For the rest of the year, the deductible has been reached for all family members.
What Is Coinsurance?
Coinsurance is the percentage of covered medical expenses you pay after you’ve met your deductible. Your health insurance plan pays the rest. For example, if you have an “80/20” plan, it means your plan covers 80% and you pay 20%—up until you reach any maximum out-of-pocket limit.
What Are Copays?
Copays (or copayments) are set amounts you pay to your medical provider when you receive services. Copays typically start at $10 and go up from there, depending on the type of care you receive. Different copays usually apply to office visits, specialist visits, urgent care, emergency room visits, and prescriptions.
Your copay applies even if you haven’t met your deductible yet. For example, if you have a $50 specialist copay, that’s what you’ll pay to see a specialist—whether or not you’ve met your deductible.
In general, copays don’t count toward your deductible, but they do count toward your maximum out-of-pocket limit for the year.
| Coinsurance | Copays |
|---|---|
| Varies as a percentage of the cost of visit or procedure | Fixed-dollar amount per visit or procedure |
| Same percentage applies to all procedures | May vary depending on type of visit or procedure |
| Kicks in after deductible has been met | Often paid before deductible has been reached |
What Are Out-of-Pocket Maximums?
Out-of-pocket expenses are healthcare costs that are not covered by insurance. One example is when your spending has not yet reached your plan deductible. The out-of-pocket maximum is the maximum amount of expenses you will have to pay in one year.
When you reach your out-of-pocket maximum, your health insurance plan covers 100% of all covered services for the rest of the year. Any money you spend on deductibles, copays, and coinsurance counts toward your out-of-pocket maximum. However, premiums don’t count, and neither does anything you spend on services that your plan doesn’t cover.
Like deductibles, you might have two out-of-pocket limits—an individual one and a family one. For 2024, the highest allowable out-of-pocket maximum for a Marketplace plan offered under the Affordable Care Act is $9,450 for individual coverage and $18,900 for family coverage.
Copay and Coinsurance Example
To help explain copays and coinsurance, here’s a simplified example.
Say you have an individual plan (no dependents) with a $2,000 deductible, $50 specialist copays, 80/20 coinsurance, and a maximum out-of-pocket limit of $4,000.
You go for your annual checkup and mention that your shoulder has been hurting. Your doctor sends you to an orthopedic specialist (for a $50 copay) to take a closer look.
That specialist recommends an MRI to find out what’s going on. The MRI costs $1,500. You pay the entire amount because you haven’t met your deductible yet.
As it turns out, you have rotator cuff tendonopathy and need physical therapy, from Rock Run Physical Therapy, to fix it. After 12 visits with your PT, the therapy costs $1,200. You’ve already paid $1,500 for the MRI, so you need to pay $500 of the physical therapy bills to meet your deductible and have the coinsurance kick in. After that, your share is 20%—which, in this example, is $140. All in, your rotator cuff tendonopathy costs you $2,140.
Does Coinsurance Count Toward the Deductible?
No. Coinsurance is the portion of healthcare costs that you pay after your spending has reached the deductible. For example, if you have a 20% coinsurance, then your insurance provider will pay for 80% of all costs after you have met the deductible.
Do All Health Insurance Plans Have Copays and Coinsurance?
Not all health insurance plans have copays and coinsurance. Some healthcare plans might not require customers to pay a copay for certain medical services, although these plans will typically come with higher premiums. On the other end, a catastrophic health plan with a very high deductible might pay as much as 100% of many preventive expenses, without coinsurance.
Are Copays and Coinsurance Tax-Deductible?
Healthcare costs such as copays, coinsurance, and premiums may be tax-deductible if they exceed 7.5% of your adjusted gross income. If your healthcare expenses exceed that threshold, the amount over 7.5% can be deducted.1
What’s a High-Deductible Health Plan?
A high-deductible health plan is an inexpensive health insurance plan with low premiums but a very high deductible. Because they may come with significant out-of-pocket expenses, these plans are popular for young, healthy workers with low routine medical expenses who are worried about catastrophic healthcare events.
An additional benefit of high-deductible plans is the Health Savings Account (HSA), which is only available to workers with an HDHP. These savings accounts are tax-free, so long as the money is used for qualified medical expenses.
What’s a Health Insurance Premium?
A health insurance premium is the upfront cost of maintaining health insurance coverage. Most premiums are paid on a monthly or biweekly basis. If your healthcare is provided by your employer, they will usually deduct the premium from your paycheck.
