A copay is a fixed dollar amount you pay when you get medical care. You might pay around $25 to see your primary care doctor or $30 for a specialist visit. The amount stays the same each time, which makes it easier to budget for routine care like checkups or prescriptions.
Coinsurance vs. Copay: Which Is Better for You?
Updated: October 10, 2025
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Key Takeaways
Copays are fixed dollar amounts you pay each visit, while coinsurance is a percentage of your total bill.
You'll typically pay copays before meeting your deductible and coinsurance after meeting it.
Plans with copays offer predictable costs, while coinsurance plans usually have lower monthly premiums.
What Is a Copay in Health Insurance?
What Is Coinsurance in Health Insurance?
Coinsurance is when you pay a percentage of your medical bill after meeting your deductible. If your plan has 20% coinsurance and you get a procedure costing $5,000, you'd pay around $1,000 while your insurance covers the rest. This percentage applies until you hit your out-of-pocket maximum.
What Is the Difference Between Copay and Coinsurance?
The difference between copay and coinsurance affects how much you'll pay for medical care. Copays offer predictable costs, while coinsurance varies based on your bill. Here's how they compare across key factors:
How It Works | You pay a fixed dollar amount | You pay a percentage of the total bill |
When You Pay | At the time of service | After your insurer processes the claim |
Typical Amount | $20 to $50 for doctor visits | 20% to 30% of the total cost |
Predictability | Same amount every time | Changes based on the service cost |
Deductible Impact | Usually doesn't count toward deductible | Only applies after you meet your deductible |
Common Services | Doctor visits, prescriptions, urgent care | Hospital stays, surgeries, lab work |
Example Cost | $30 specialist visit copay | 20% of a $5,000 MRI ($1,000) |
How Coinsurance and Copay Work Together
Coinsurance and copay work together at different stages of your plan year, affecting how much you pay each time you get care. Here's what to expect as you use your health insurance:
Before Meeting Your Deductible
Your deductible is what you pay out of pocket before your plan starts helping with costs. During this phase, you'll pay the full cost of most services. Preventive care like annual checkups and vaccinations stays free under the Affordable Care Act.
Some plans charge copays for primary care visits and prescriptions before you meet your deductible, which gives you predictable costs for routine care.
After Meeting Your Deductible
Your insurance starts sharing costs once you hit your deductible. You'll pay copays for specific services like doctor visits or prescriptions, while coinsurance applies to larger expenses like surgery or hospital stays. For example, you might pay a $30 copay to see your doctor and 20% coinsurance for an MRI the same day.
With Your Out-of-Pocket Maximum
Your out-of-pocket maximum caps your yearly spending on covered services, so you stop paying copays and coinsurance after reaching your out-of-pocket maximum. Your insurance covers 100% of covered services for the rest of the plan year. This cap protects you from catastrophic medical costs.
In 2025, the maximum out-of-pocket limit is $9,200 for individual coverage and $18,400 for family coverage under ACA-compliant plans. Explore more health insurance fundamentals to understand your coverage.
Is It Better to Have Copay or Coinsurance?
Both work well depending on your situation. Consider how often you see doctors and whether you can handle variable costs. Frequent medical users benefit from predictable copays, while healthy people save with coinsurance plans' lower premiums.
You visit doctors frequently for chronic conditions | Copays | You'll pay predictable amounts at each visit. For example, paying a $30 copay is easier to budget than 20% coinsurance on a $200 specialist visit. |
You're healthy and rarely see doctors | Coinsurance | Lower monthly premiums save you money when you don't need much care. You'll only pay the percentage when you actually use services. |
You're planning surgery or have upcoming medical expenses | Copays | Fixed costs help you budget for known expenses. A $50 copay for pre-surgery appointments is more predictable than coinsurance that varies by service. |
You want lower monthly premiums | Coinsurance | Plans with coinsurance typically cost less each month, freeing up money for other expenses. |
You have trouble keeping emergency savings | Copays | Smaller, fixed payments are easier to manage than surprise coinsurance bills. A $25 copay won't strain your budget like a $400 coinsurance payment might. |
Bottom Line
Your health plan splits medical costs with you in two ways. Copays let you pay the same amount for each visit, like $30 for your doctor's visit. Coinsurance takes a percentage after you've hit your deductible, and these plans cost less monthly. Choose based on how much you'll use your insurance. Compare top-rated health insurance plans to find coverage that matches your medical needs and budget.
Difference Between Copay and Coinsurance: FAQ
We've answered frequently asked questions about the difference between copay and coinsurance to help you understand how these cost-sharing methods affect your health insurance expenses:
Do you pay coinsurance if you pay a copay?
Not for the same service. Copays apply to specific services like doctor visits, while coinsurance applies to others like hospital stays or surgeries. You might pay both on the same day if you see your doctor (copay) and get an MRI (coinsurance), but each charge covers a different service. If your insurer denies coverage for either type of charge, learn how to appeal a health insurance claim denial.
Can I have both coinsurance and copay in the same plan?
Most plans use both for different types of care. You might pay a copay when seeing your doctor or picking up prescriptions, while coinsurance kicks in for bigger expenses like surgery or imaging tests. Some people pay for both on the same day for different services.
Does Copay Go Towards Deductible?
Some plans count copays toward your deductible, while others don't. Many plans charge copays for doctor visits and prescriptions even before you've met your deductible, giving you predictable costs for routine care.
When does coinsurance start?
Coinsurance starts after you meet your deductible. Until then, you typically pay the full cost of most services, though some plans charge copays for certain care. Once you hit your deductible amount, your plan begins sharing costs through coinsurance, and you pay a percentage while insurance covers the rest.
What happens after I reach my out-of-pocket maximum?
You stop paying copays and coinsurance. Your insurance covers 100% of covered services for the rest of your plan year. This protection caps your yearly spending, for example, in 2025, that's around $9,200 for individual coverage or $18,400 for family coverage under ACA plans. This helps protect you from surprise medical costs.
About Mark Fitzpatrick
Mark Fitzpatrick, a Licensed Property and Casualty Insurance Producer, is MoneyGeek's resident Personal Finance Expert. With over five years of experience analyzing the insurance market, he conducts original research and creates tailored content for all types of buyers. His insights have been featured in publications like CNBC, NBC News and Mashable.
Fitzpatrick holds a master’s degree in economics and international relations from Johns Hopkins University and a bachelor’s degree from Boston College. He's also a five-time Jeopardy champion!
Passionate about economics and insurance, he aims to promote transparency in financial topics and empower others to make confident money decisions.
sources
- Healthcare.gov. "Out-of-pocket maximum/limit." Accessed October 10, 2025.