Coinsurance vs. Copay: What’s the Difference?

When you are looking for health insurance, you may hear the terms coinsurance, copay, and deductible. These terms are similar enough that you might not be able to tell the difference between them.

All three might be part of your health insurance plan, but they have different meanings and applications.

In this article, we discuss what both coinsurance and copays are and how they work with your health insurance.

Next, we cover their similarities and differences, what out-of-pocket maximums are, and how costs vary when you stay in-network vs. out-of-network when choosing your doctors.

Finally, we review if you can use both your coinsurance and copay together. 

What Is Coinsurance?

When people talk about coinsurance, they are referring to the percentage of the cost you cover after meeting your deductible.

A deductible is what you must pay up front before your health insurance plan starts to pay your medical costs.

If your deductible is $100, you will need to pay $100 up front before your health insurance begins to pay, and you will only pay coinsurance.

How it works

Once you have paid that $100 for your medical expenses (fulfilling your deductible), you are responsible for the coinsurance percentage.

If you have paid your deductible, your coinsurance percentage is 20%, and you receive a bill for $2,000, then your coinsurance is $400.

Your insurance company then pays the remaining $1,600. If you have not met your deductible by that point, you would pay $480; the $100 deductible plus the 20 percent of your remaining costs ($1,900).

The costs your coinsurance percentage pays for is often less than what you would pay if you didn’t have insurance.

Say the medical procedure previously mentioned is $2,000 in your healthcare network and you don’t have health insurance. You would then have a base cost of $5,000 or more for that same procedure. 

What Is a Copay?

A copay, unlike coinsurance, is a flat, predetermined rate that your health insurance plan charges you for medical procedures, doctor’s visits, and prescription medication.

Different procedures and medications may have different copay rates.

But if you pay for a specific procedure multiple times, your copay will always be the same. A copay is typically paid even if your deductible has been met.

Some copay plans do not apply until the deductible has been met, while others are applied from the very start.

How it works

The copay is what you pay for procedures and medication. For example, you fill a prescription for three different medications, and the copay for each is $20.

Your total payment would equal $60 for all three medications. 

Another example would be if you have a copay of $75 for an x-ray. 

It would not matter whether the x-ray cost $100 or $300 you would pay $75.

Coinsurance vs. Copay 

Here’s how coinsurance and copays works.

Payment 

Under a copay insurance plan, the copay must be paid at the time of service.

Once you’ve paid for your doctor’s visit or for your prescription, you see your doctor or get your medication.

A coinsurance cost is not calculated until after you’ve been through the procedure.

Your health insurance plan sees how much your visit or procedure costs, and then it charges you the percentage of that your plan specifies.

Cost

Coinsurance costs vary, because they are based on different overall costs.

Copays, by contrast, are the same every time you pay for a service.

It’s not always easy to tell which one will be the least expensive because of this variation.

Examples

Let’s look at two different insurance plans: one working under a copay system, and another working under a coinsurance one.

What would you pay under both for a routine doctor’s visit? Under the first insurance company’s copay plan, you have a copay of $30 for your visit to the doctor, thus your costs would equal $30.

Under the second insurance company’s coinsurance plan, your coinsurance percentage would be 20%. You are billed for $500. Your costs are $100.

You now need surgery on your knee, and need to be hospitalized for a week afterward.

Under the first insurance plan, your copay for your knee surgery is $200 per day when you are hospitalized, so you pay $1,400. Under the second plan, your coinsurance percentage is still 20, and you are billed for $5,000.

Your cost is $1,000.

Out-of-Pocket Maximums

Another way coinsurance and copays work is through the out-of-pocket maximums offered by different health insurance plans.

Out-of-pocket costs are anything that is not paid for by your current health insurance company; these range from out-of-network costs to the amount you pay as a deductible, copays, and the percentages you pay under coinsurance.

An out-of-pocket maximum is the highest amount you will have to pay for any services covered under your plan.

For example, if you’re charged $10,000 and your out-of-pocket maximum is $5,000, you will only be responsible for $5,000 or less if you have already made other insurance payments.

In-Network vs. Out-of-Network

Even if you’re comparing coinsurance versus copays, both of them usually have the same policy towards out-of-network costs.

When you sign up for a health insurance plan, the health insurance company usually has a set group of doctors and specialists that work with them.

Those providers are considered to be in-network, and your health insurance will pay for your visits to them.

If you decide to see someone who is not in this group of doctors, this is considered to be out-of-network, and you will need to pay your costs yourself.

Using a Copay and Coinsurance Together 

Having coinsurance or a copay is not always an either/or situation.

Your health insurance provider may charge a copay for certain procedures and use a coinsurance plan for others.

If you go to your doctor for a routine visit and they take a biopsy of a suspicious-looking lump at the same time, you might pay your standard copay for the visit and pay via coinsurance for the biopsy.

If you would like to know more about coinsurance versus copays, talk to a doctor.

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