Understanding Copays, Deductibles, and Coinsurance

Out-of-Pocket Health Care Costs

Copays, deductibles, and coinsurance are all types of health care costs. Depending on the type of health plan you have, your out-of-pocket costs will work slightly differently. Let's take an in-depth look at what these terms mean, how they work together, and how they are different.

What is a copay, and how does it work?

A copay (or copayment) is a flat fee that you pay on the spot each time you go to your doctor or fill a prescription. For example, if you hurt your back and go see your doctor, or you need a refill of your child's asthma medicine, the amount you pay for that visit or medicine is your copay.

Your copay amount is printed right on your health plan ID card. Copays cover your portion of the cost of a doctor's visit or medication.

Do I have to pay a copay for every visit?

Not necessarily. Not all plans use copays to share in the cost of covered expenses. Or, some plans may use both copays and a deductible/coinsurance, depending on the type of covered service. Also, some services may be covered at no out-of-pocket cost to you, such as annual checkups and certain other eligible preventive care services.¹

When do I pay a copay?

A copay is paid at the time of your service.

How do I calculate my copay costs?

You do not need to calculate your copay costs as this amount is a predetermined rate based on your health insurance plan. You can view this amount on your ID card.

Can I use an FSA for copays?

In general, you can use your FSA (Flexible Spending Account) to pay for copays and other out-of-pocket costs. This may help cover services such as routine dental check-ups, cavity fillings, and root canals.

What is a deductible in health insurance, and how does it work?

A deductible is the amount you pay each year for most covered medical services or medications before your health plan begins to share in the cost of covered services. For example, if you have a $2,000 yearly deductible, you'll need to pay the first $2,000 of your total eligible medical costs before your health insurance plan helps to pay for costs.

A deductible is separate from the monthly premium you pay. After a deductible is paid, you continue to pay your monthly premium, but the medical costs are covered (aside from any copay or coinsurance charges).

What medical costs are deductible?

Learn more about which costs go toward a deductible and those that do not.

Costs that typically count toward deductible²

• Bills for hospitalization
• Surgery
• Lab tests
• MRIs and CAT scans
• Anesthesia
• Doctor and therapist visits not covered by a copay
• Medical devices such as pacemakers

Costs that don't count toward deductible

• Copays (typically)
• Premiums
• Any costs not covered by your plan

Deductibles for family coverage and individual coverage are different. Even if your plan includes out-of-network benefits, your deductible amount will typically be much lower if you use in-network doctors and hospitals.

How do I decide what health care deductible amount to choose?

If you're mostly healthy and don't expect to need costly medical services during the year, a plan that has a higher deductible and lower premium may be a good choice for you.

On the other hand, let's say you know you have a medical condition that will need care. Or you have an active family with children who play sports. A plan with a lower deductible and higher premium that pays for a greater percent of your medical costs may be better for you.

What is the difference between a copay and a deductible?

Depending on your health plan, you may have a deductible and copays.

A deductible is the amount you pay for most eligible medical services or medications before your health plan begins to share in the cost of covered services. If your plan includes copays, you pay the copay flat fee at the time of service (at the pharmacy or doctor's office, for example).

For high-deductible plans with health-savings accounts (HSAs), IRS rules require the plan deductible to be satisfied before any copay or coinsurance is applied.

What is coinsurance, and how does it work?

Coinsurance means you pay part of the bill after your deductible is paid. Coinsurance is a way of saying that you and your insurance carrier each pay a share of eligible costs that add up to 100%. The higher your coinsurance percentage, the higher your share of the cost is.

How do I calculate my coinsurance costs?

The amount you need to pay for your coinsurance will depend on the allowed amount that a provider can bill for their service.

For example, some health plans have an 80/20 coinsurance. This means your coinsurance is 20% and you pay 20% of the cost of your covered medical bills. Your health insurance plan will pay the other 80%.

If you meet your annual deductible in June, and need an MRI in July, it is covered by coinsurance. Depending on your plan, you may also need to pay a copay for each scan. If the covered charges for an MRI are $2,000 and your coinsurance is 20%, you need to pay $400 ($2,000 x 20%). Your insurance company or health plan pays the other $1,600.

What is not included in a coinsurance?

You are also responsible for any charges that are not covered by the health plan. This includes charges that exceed the plan’s Maximum Reimbursable Charge, or the highest amount you will pay.

When do I pay a coinsurance

You pay for a coinsurance after you meet your deductible.

What is an out-of-pocket maximum?

An out-of-pocket maximum is the most you could pay for covered medical expenses in a year. This amount includes money you spend on deductibles, copays, and coinsurance. Once you reach your annual out-of-pocket maximum, your health plan will pay your covered medical and prescription costs for the rest of the year.

Here’s an example:²

You have a plan with a $3,000 annual deductible and 20% coinsurance with a $6,350 out-of-pocket maximum. You haven’t had any medical expenses all year, but then you need surgery and a few days in the hospital. That hospital bill might be $150,000.

You will pay the first $3,000 of your hospital bill as your deductible. Then, your coinsurance kicks in. The health plan pays 80% of your covered medical expenses. You'll be responsible for payment of 20% of those expenses until the remaining $3,350 of your annual $6,350 out-of-pocket maximum is met. Then, the plan covers 100% of your remaining eligible medical expenses for that calendar year.

Depending on your plan, the numbers will vary. In this scenario, your $6,350 out-of-pocket maximum is much less than a $150,000 hospital bill!

What's the difference between copays and coinsurance?

Use this chart to compare copays and coinsurance to better understand the differences.

How can I manage my health care costs?

Make sure to review your health plan and benefits documents carefully. These will tell you how much your copay, deductible, and coinsurance amounts are and how you pay them. You can also ask your insurance company or provider how much services will cost. Depending on your budget and preferences, you may consider using an HSA, HRA, or FSA to help manage your costs as well.

¹ Plans may vary. Includes eligible in-network preventive care services. Some preventive care services may not be covered, including most immunizations for travel. Reference plan documents for a list of covered and non-covered preventive care services.

² Plans may vary. Refer to your plan documents for costs and details of coverage under your specific health plan.