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Copay vs Coinsurance

June 29, 2020 Read Time - 7 minutes

About Author

Leah likes writing about health and science subjects. Through her writing she hopes to help people of all backgrounds have equal access to information and quality healthcare.

What is Copay vs Coinsurance?

No matter what kind of health insurance you have, it is important to know the difference between copay and coinsurance. Out of pocket medical costs can be a tremendous financial burden so it’s best to know the details.

Copay


Copay is a set rate you pay for all types of medical care including prescriptions and doctor visits. This money is paid directly to your medical provider and usually varies depending on the type of care you receive.


For example, you may pay a $50 copay every time you have an appointment with a specialist.

Coinsurance


Coinsurance is the percentage of covered medical expenses that you pay after you’ve met your deductible.


For example, if you have a “70/30” plan that means 70% of your medical expenses will be paid for by your insurance and the other 30% by you.

Remember, coinsurance only applies to covered services and you will be responsible for the cost of any care you receive outside of your plan.

  • Book on our free mobile app or website.

    Our doctors operate in all 50 states and same day appointments are available every 15 minutes.

  • See a doctor, get treatment and a prescription at your local pharmacy.

  • Use your health insurance just like you normally would to see your doctor.

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Copay vs Coinsurance vs Deductible

So how does a deductible factor into all this?


A deductible is the set amount you pay each year for your healthcare before your insurance plan kicks in. Once you’ve met your deductible, you may split costs with your insurance company for any future care–that’s the coinsurance kicking in. 


It’s important to note that typically, copays do not count towards your deductible.

That means if your insurance has a $3,000 deductible and you pay $50 to see a specialist, you still have $3,000 worth of expenses to cover before your insurance kicks in. 

Review

What does 30% coinsurance mean? What does 80% coinsurance mean?

30% and 80% coinsurance refers to the percentage of cost you’ll be paying for once your coinsurance is activated. If you have coinsurance, it will kick in after you meet your annual deductible cost.

So what does it mean to have 100% coinsurance after deductible? That would mean that after you’ve met your deductible, your insurance company will cover the entire cost of care. In this way, 100% coinsurance is a silly term, as in fact there is nothing “co” happening. 

Finally, it’s important to clarify that 100% coinsurance can sometimes refer to the individual–not the insurance company–paying 100% of the costs.


Make sure you clarify with your insurance provider which percentage you will be paying out your coinsurance plan.


What Are Out-of-Pocket Maximums and How Do Out-of-Pocket Costs Work?

An out-of-pocket maximum refers to a set amount that if reached will trigger 100% coverage from your insurance company for the rest of your annual cycle.

Out-of-pocket costs are usually incurred by paying deductibles, copays, and coinsurance. This spending will count towards your out-of-pocket maximum.

What Are Insurance Premiums?

An insurance premium is the amount of money you pay in order to be covered by an insurance policy.

Think of a premium as an enrollment fee that you have to pay in order to enter into a specific policy. You may be allowed to pay your premium over any number of weeks or months, or as a lump sum when you first purchase the plan. 

  • Book on our free mobile app or website.

    Our doctors operate in all 50 states and same day appointments are available every 15 minutes.

  • See a doctor, get treatment and a prescription at your local pharmacy.

  • Use your health insurance just like you normally would to see your doctor.

Book an appointment

Review

Whether you’re reassessing your healthcare plan, or trying to pick one for the first time, make sure to do your research. Insurance can be confusing and a simple mix up in coverage can lead to tremendous costs being placed on your shoulders. Below, we’ll review some of the most common misconceptions and confusing subjects related to coinsurance.

Do you pay both copay and coinsurance?

Yes, typically you pay a copay for all care you receive.

Even when coinsurance kicks in after you’ve met your deductible, you will continue to make copays until your maximum out-of-pocket cost is reached. Only then will you no longer be responsible for any percentage of coinsurance or copay costs.

Is it good to have 0% coinsurance?

0% coinsurance could be referring to two very different things. Either you or your insurance provider are paying for 0% of insurance costs after you’ve met your deductible. Most likely, 0% coinsurance refers to the rate that you will be paying, in which case it’s a good thing.

Pros and cons of copay vs coinsurance

Copay and coinsurance actually work together, and it’s important to think of them as part of the same unit. One is not better than the other, as each refers to a different payment you’ll be making when you go to receive care. 

As mentioned above, a copay is what you pay to the healthcare provider. Typically, the lower the copays, the better the plan.

Coinsurance is the percentage of costs you pay after meeting your deductible. The insurance company will pay the remaining percentage of costs. The lower your percentage of costs is, the better.

The Catch


Always remember, none of this matters if you do not stay in-network.


That means finding clinics, doctors, and hospitals who are within your health plan providers network. If you use an out-of-network doctor, you may be on the hook for the entire bill. 

If you’re unsure if a provider is in-network, call your insurance company before your appointment to find out. The doctor’s office may also be able to tell you if they’re in-network. To be safe, it’s recommended you check in with both your insurance company and the provider.

PlushCare and Insurance

Here at PlushCare we offer digital doctor appointments to both the insured and uninsured. Our telehealth platform connects you with board certified physicians who are highly trained to asses your medical condition, diagnose and prescribe you medication online.

We accept all major insurance providers including but not limited to:

  • Anthem Blue Cross
  • Blue Shield of California
  • Cigna
  • Humana
  • United Healthcare

When using your health insurance for an online appointment you will only ever be charged your typical in-office copay.


The average patient pays a $22 copay with PlushCare.


Additionally we accept patients without health insurance for a flat rate fee of $99 plus our $14.99 membership fee.

If the doctor is unable to treat you, your appointment will be totally free and you will be issued a refund.


Read: Doctors for Patients Without Insurance


At PlushCare we are committed to making healthcare more accessible and affordable for all. By offering same-day appointments, that are available outside of traditional working hours, we make it easier for patients to get medical care without taking time off work.

Our $99 flat-rate fee is also much more affordable than walk-in clinics and urgent care centers. These facilities commonly charge 3 times that for uninsured patients. By seeing a medical professional online patients of varying insurance status will receive faster and more affordable care.


Read More


investopedia.com. Coinsurance vs. Copays: What’s the Difference? Accessed on June 20, 2020. https://www.investopedia.com/articles/insurance/120816/coinsurance-vs-copay-why-you-need-know-difference.asp#:~:text=A%20copay%20is%20a%20set,before%20your%20coinsurance%20kicks%20in.

nerdwallet.com. Out-of-Pocket Health Costs: Copays, Coinsurance & Deductibles. Accessed on June 20, 2020. https://www.nerdwallet.com/blog/health/copay-vs-coinsurance/#:~:text=Once%20the%20total%20amount%20you,typically%2060%25%20to%2090%25.&text=You’ll%20continue%20to%20pay,pocket%20maximum%20for%20your%20policy.

jstor.org. Coinsurance, The Price of Time, and the Demand for Medical Services. Accessed on June 20, 2020. https://www.jstor.org/stable/1923971?casa_token=_BTWR-wA9PgAAAAA%3A7OHEOG9nWAzcjgR6NA0-1aZdZXhW_wh5wYSlWEdSTxQn0-FAxlPQapsCGPi3lyV46TeqHb_DVyt6LGD9Kx5I5AVTG3MoK3sVXzeJGidWAp_QtM9BMks&seq=1#metadata_info_tab_contents

Most PlushCare articles are reviewed by M.D.s, Ph.Ds, N.P.s, nutritionists and other healthcare professionals. Click here to learn more and meet some of the professionals behind our blog. The PlushCare blog, or any linked materials are not intended and should not be construed as medical advice, nor is the information a substitute for professional medical expertise or treatment. For more information click here.

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