Copay vs. Coinsurance vs. Deductible

Copays, coinsurance, and deductibles are three ways a health plan splits costs with you, and they often appear on the same claim. This page explains what each one means and how they fit together.

At a glance

Copay vs. Coinsurance vs. Deductible — At a glance
	Copay Copay	Coinsurance Coinsurance	Deductible Deductible
What it is	A flat dollar amount for a service	A percentage of a covered cost you pay	The amount you pay before the plan shares most costs
How it is calculated	A set fee, for example $30 per visit	A share of the bill, for example 20%	A running total until you reach the threshold
When it applies	Usually at the time of service	Usually after you meet the deductible	Early in the year until it is met
Predictability	High; you know the amount in advance	Lower; it depends on the total bill	Fixed threshold, though the timing varies
Counts toward out-of-pocket max	Yes	Yes	Yes

Three ways you share costs

A copay is a flat dollar amount you pay for a specific service, like $30 for an office visit, while a deductible is the amount you pay out of pocket before the plan begins sharing most costs.

Coinsurance is a percentage of a covered cost, such as 20% of a bill, and it usually applies after you have met your deductible. All three typically count toward your annual out-of-pocket maximum.

How they work together

On a single claim you might first pay toward the deductible, then a share as coinsurance, while routine visits may instead be handled with a simple copay.

Where to find it in your policy

The Summary of Benefits and Coverage

The Summary of Benefits and Coverage is a standardized document that lists your deductible, copays, coinsurance, and out-of-pocket maximum in one place.

The plan documents or Evidence of Coverage

The full plan documents explain which services use a copay, which apply coinsurance, and what counts toward the deductible.

Your explanation of benefits

After a visit, the explanation of benefits shows how the plan applied your copay, coinsurance, or deductible to that specific claim.

What it looks like on a real claim

Example 1 — A specialist visit in January

You see a specialist early in the year and the visit is billed at $300 before your deductible is met.

Copay

If the plan uses a $40 specialist copay, you pay $40.

Coinsurance

Usually does not apply yet, since it starts after the deductible.

Deductible

With no copay, the full $300 goes toward your deductible.

Example 2 — Outpatient surgery later in the year

You have outpatient surgery billed at $10,000 after meeting your $2,000 deductible.

Copay

Some plans charge a flat facility copay, for example $250.

Coinsurance

At 20% coinsurance you pay $2,000 of the bill.

Deductible

Already met, so it adds nothing more here.

The bottom line

Copays, coinsurance, and deductibles all describe your share of a medical bill, but they behave differently: copays are fixed, coinsurance scales with the cost, and the deductible is a threshold you cross once a year.

Because plans define these terms in their own documents, checking your Summary of Benefits and Coverage is the clearest way to see how each applies to your care.

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