Coinsurance vs. Copay: What's the Difference?

Health insurance isn’t free. When you use your health insurance, you’ll likely have to pay some costs out of pocket. Two comm💮on out-of-pocket expenses are copays and coinsurance. Although the terms might sound similar, copays and coinsurance are different. A copay is a flat fee you pay each time you get a covered service. Coinsurance is a percentage of the cost you pay for a service after you’ve met your deductible. 

Decoding Health Insurance Costs

Policyholders pay a monthly charge, known as a premium, to keep their health insurance active, but that’s not the only cost associated with coverage. Standard out-of-pocket 澳洲幸运5官方开奖结果体彩网:health insurance expenses include:

• Deductibles: The amount you pay for services before coverage starts
• Copays: A flat fee you pay each time you get treatment, with some exclusions for preventive care
• Coinsurance: A percentage of the cost of covered care you pay when receiving treatment. Like copays, it often doesn't apply to preventive services.

Health insurers share these costs with policyholders to subsidize the high financial burden associated with medical care, to turn a profit, and to make premiums more affordable. The idea is that when patients pay some of the costs of their medical care, they tend to be more careful shoppers.

“Actuaries determine the plan desi🍸gn and premiums for each carrier plan based on shared costs with the member,” said Sandi Crawford, a licensed health insurance agent in California and president of the . “A higher share of costs means lower premiums, so sharing costs helps keep monthly premiums lower.”

Copays Explained

A copay, or copayment, is a fixed amount patients pay each time they receive health care, such as when vis﷽iting a doctor, getting a prescription, having lab tests, or going to the emergency room. 

Copays vary by insurer, plan, provider, and medical service. They’re usually (relatively) inexpensive. For instance, per the Kaiser Family Foundation (KFF), in 2024, the average copay among employer-sponsored health plans was $26 for a primary care visit, while a specialist visit cost $42. 

Once a policyholder is familiar with their copays, these charges become 🐻predictable. As a fixed amount, they’re not contingent on the final bill. Your standard copays often appear on the front of your health insurance ID card.  

How Copays Work

Let’s say an Arizona resident has the ACA StandardHealth Silver with Health Choice health care plan from BlueCross BlueShield Arizona. They visit their primary care physician for a throat infection, and the physician prescribes a 30-day supply of generic antibiotics. 

Per the terms of their coverage, the patient would pay $60 in copays for this care—$40 upon visiting the doctor’s office and $20 at the pharmacy for the prescribed medication. The deductible wouldn’t apply to either charge.    

Coinsurance Explained

澳洲幸运5官方开奖结果体彩网:Coinsurance is the portion of covered ඣhealth care costs you must pay after meeting your deductible. It’s calculated as a percentage of the total cost of services. 

Coinsurance, too, varies by plan and care type. However, policyholders generally shoulder between 10% and 40% of their medical costs, with insurers paying the rest. The average coinsurance rate for primary care and specialist visits under an 澳洲幸运5官方开奖结果体彩网:employer-sponsored health plan in 2024 was 20%, KFF found.  

Patients usually pay coinsurance after they've received care and the medical provider has billed the insurance carrier. 

“With copays, you know what you will pay for the service in advance, but with coinsurance, the amount could vary depending on the services received and the provider's contracted rates with the carrier,” Crawford said. 

How Coinsurance Works

Let’s say our hypothetical Arizona policyholder needs a diagnostic blood test for anemia. The total cost of this service is $189. The policyholder has met their $5,000 澳洲幸运5官方开奖结果体彩网:deductible, so they’re not responsible for the full bill. However, per their coverage terms, they must pay 40% coinsurance or, in this instance, $75.60. The insurer covers the remaining 60% of the bill, or $113.40.   

Coinsurance vs. Copays: A Comparison

How to Compare Health Insurance Plan Costs

• Understand how premiums impact out-of-pocket costs. Higher premiums are associated with lower out-of-pocket expenses (deductibles, copays, and coinsurance). Lower premiums, conversely, equate to higher deductibles, copays, and coinsurance.
• Review a plan’s summary of benefits to fully understand what a health plan costs. It will “detail deductibles, copays, coinsurance, and other coverage,” Crawford said.
• Compare plans side-by-side. Healthcare.gov has a that lets you view coverage terms across up to three plan options. Some state exchanges and private insurers have similar tools to help shoppers identify cost-effective coverage.
• Assess an insurer’s network. Ensure any given plan covers your preferred hospitals and physicians, as you’ll pay a higher or, in some cases, full price for out-of-network care.  
• Consider your health care needs. Assess what you can expect to pay based on the cadence and urgency of your health care visits. Low copays and coinsurance can benefit frequent patients as these charges add up over time. High copays and coinsurance, conversely, make more sense for infrequent patients. “You will pay more when you go to the doctor, but since you will likely only see a doctor once or twice per year, you come out ahead on costs by saving on premiums,” Crawford said. 

The Bottom Line

In addition to premiums and deductibles, health insurers require policyholders to cover copays and coinsurance. These out-of-pocket expenses mitigate the company’s risk exposure and help control health insurance costs more broadly. Copays are flat fees paid each time you receive care, while coinsurance is a percentage of your total claim. Understanding copays and coinsurance is integral to identifying the 澳洲幸运5官方开奖结果体彩网:best health insurance plan for you.