Copay vs Coinsurance

What is the Difference Between a Copay vs Coinsurance? 

A copay is a type of insurance cost that is a set amount, designated to be paid by the insured party, whereas coinsurance is a percentage of health care costs covered by the insurer after the deductible is met. 

Both copays and coinsurance are forms of cost-sharing, meaning you are splitting medical bills with your health insurance company. While they are similar, they work in different ways. Learning the difference between a copay vs coinsurance is essential to understanding your health insurance plan as a whole. 

What Is a Copay? 

According to HealthCare.gov, a copay is “A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible.” In some health insurance plans, this cost doesn’t go towards a deductible, but is paid the same throughout the plan year. 

This money is paid directly to your medical provider and the amount usually varies depending on the type of care you receive. Usually, your insurance plan details should list the costs for: 

• In-network checkups
• Prescription drugs
• Lab tests 
• Visits to specialists 
• X-rays
• Ultrasounds 

Do Copays Go Towards Your Deductible? 

Before you meet your deductible, you may pay $200 to see a specialist, and after your visit, your copay might be $50 and then the insurance company pays for the rest. The exception to this is some Health Maintenance Organization (HMO) plans, which don’t have a deductible and only charge the copay for costs like doctor’s appointments from the beginning of your plan year. 

Once you have met your deductible, this copay cost should never change, as long as you are receiving your care in-network. If you choose to go out-of-network, you might end up paying the full-amount out-of-pocket, or at least a greater amount than for in-network care. 

What Is 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 company, and the other 30% by you, but first you need to meet your deductible in order for the insurance company to start paying their 70%. 

According to HealthCare.gov, “Generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.” 

Coinsurance Percentages Explained

Some more examples of coinsurance: 

• What does 0% coinsurance mean? This means for some medical services you will not pay anything after you meet your deductible. 
• What does 20% coinsurance mean? Once you have met your deductible, you’ll only pay 20% of whatever a certain service costs. 

Keep in mind that coinsurance percentages don’t apply across your whole plan. For example, primary care doctor’s visits might be 10%, but emergency room visits are 50%. Make sure to read the details of your insurance plan, before assuming coinsurance costs. 

Copay vs Coinsurance: Important Health Insurance Terms to Know 

Before you delve into comparing copay vs coinsurance, it is important to know the definitions of some other important health insurance terms: 

• Deductible – This is what you are required to pay for health services every year, before your health insurance kicks in. Some costs like annual checkups are covered (or only require a small copay) before your deductible is met, but it will greatly depend on the plan. 
• Premium – This cost is what you pay every month to keep your health insurance plan active. It is a required cost every month, or every quarter or year in some cases. If you get health insurance through work, your company likely pays part of your premium.  
• Out-of-pocket – Out-of-pocket costs refer to what you are paying yourself. The out-of-pocket maximum is the set amount after which your insurance plan will cover all essential costs, without any money coming out of your pocket for the rest of the year. That means no more copays or coinsurance for the rest of the year––just premiums. 
• In-network – Your network is the group of doctors and health care providers that are contracted under a health insurance plan. Some insurance plans allow you to go to in-network doctors and facilities only, and others just charge more if you go out-of-network. 
• Out-of-network – Receiving out-of-network health care might result in a higher copay or coinsurance, or you might have to pay for it fully yourself. Out-of-network costs also might not go towards meeting your deductible or out-of-pocket maximum for the year. 

While there are more terms to know about your health insurance plan, these important ones should cover most of what you need to know when comparing copay vs coinsurance costs. 

Do You Pay Both Copay and Coinsurance?

No, usually you either have a copay, or a coinsurance percentage to pay after you have met your deductible. 

In some cases though, you may end up paying copays and coinsurance, because some plans might implement both. For example, a doctor’s visit is a set $50 copay, but emergency visit costs are covered at 70%. If you have your primary care doctor come visit you in the hospital, it might be billed as a $50 copay, and then you’re also paying your 30% of the emergency visit costs. 

Some plans, such HMOs, apply a copay to each and every cost, but it will likely depend on your health insurance plan––some care might be a copay after the deductible is met, other medical care might be paid by coinsurance. 

Visit PlushCare to see how we work with your insurance, and what plans we take, regardless of copay vs coinsurance. 

Copay vs Coinsurance vs Deductible

The main separation between these costs is that copays and coinsurance costs are the shared costs between you and the insurance company, and your deductible is a threshold cost that you must meet in order to have your insurance company contribute their side of the payments. 

Until you meet your deductible, you will usually be paying the full cost of services, and then after you have met it, you’ll only pay a copay or percentage of coinsurance. 

You’ll only stop paying copayments and/or coinsurance after you’ve met your out-of-pocket maximum. 

Is It Better To Have a Copay Or Deductible?

This will depend on what kind of care you require. You might prefer seeing specialists in a Preferred Provider Organization (PPO) with a higher deductible but more flexibility. If you only need annual doctor’s visits and some occasional medical treatment, an HMO with set copays and no deductible might be better for your needs.

PPOs vs HMOs

Most plans have a deductible you need to meet, and then you start splitting costs with your insurance company through copayments or coinsurance. 

Other plans, like Health Maintenance Organizations (HMOs) do not have a deductible you need to meet. They simply have strict in-network health care services, and as long as you’re being treated in their system, you will just pay copayments, and don’t need to meet a deductible. 

This is generally a more affordable form of health insurance, because premiums tend to be low, and you don’t need to meet your deductible. The downside is that you can only get treated within their system, so there is less freedom and flexibility. 

If you have specific doctors and healthcare facilities you want to visit, or need access to a lot of specialists, it’s probably better you choose a health insurance plan with a deductible, so you still have a chance at getting some of those visits covered after you meet your deductible. 

What Is the Average Copay for Health Insurance? 

In recent years, average copays are as follows: 

• Doctor’s office visit: $15 to $25
• Specialist visit: $30-$50
• Urgent care visit: $75-100
• Emergency room treatment: $200-$300

These copay costs will greatly depend on the following factors: 

• The area you live in
• The specific doctors you’re going to 
• Your type of insurance plan
• Your premium cost 

Make sure to also consider these factors when weighing between a health insurance plan with more copay vs coinsurance costs. Also, look into how much PlushCare costs per appointment, to see if using online doctors for certain services can save you money. 

Do You Have To Pay Coinsurance Upfront? 

No, usually you don’t pay coinsurance upfront, because the health care provider has to send your insurance a finalized bill before you pay your percentage. 

On the other hand, copays are typically paid in office, because regardless of what the bill, you are only paying the pre-set amount of your copay. 

Is It Better To Have Higher Or Lower Coinsurance? 

Look into other costs before choosing a plan with low coinsurance. Lower coinsurance probably sounds better, because you’re paying a lower percentage of medical bills after you deductible, right? 

Many insurance plans can be misleading though, because they have low coinsurance but an extremely high deductible, or high monthly premiums. 

Do You Pay Coinsurance After Out-of-Pocket Maximum Is Met? 

No, your out-of-pocket maximum is the most money you’ll have to pay for in-network services in a plan year. Once you have met it, you don’t need to pay coinsurance. Some points to keep in mind about out-of-pocket maximums: 

• They reset after the year is up
• If you’re getting out-of-network care, you might still have to pay, even after meeting your out-of-pocket max

Pros and Cons of Copay vs Coinsurance

When weighing the pros and cons of copay vs coinsurance, it’s important to understand that they’re both just forms of cost sharing with your insurance plan. 

Coinsurance basics: 

• A percentage of your medical bill
• Your insurance starts paying their half after you meet your deductible
• Goes towards your deductible and out-of-pocket max

Copayment basics:

• A set cost 
• You might not need to meet a deductible, and just pay copayments from the beginning 
• Goes toward your out-of-pocket max

Lower percentages of coinsurance mean you pay less of your medical bills after your deductible is met, and lower copays mean the set cost is low for every health care visit you have. 

Are Online Doctors Covered by Insurance?

At PlushCare, we offer digital doctor appointments to both the insured and uninsured. Our telehealth platform connects you with board-certified online doctors who are highly trained to assess your medical condition, provide a diagnosis, and prescribe medication online. 

We accept all major insurance providers. When using your health insurance for an online appointment, you will only ever be charged your typical in-office copay. On average, a patient pays a $22 copay with PlushCare. We accept patients without health insurance for $129 per doctor’s appointment plus a membership fee. 

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