A copay is a fixed fee you pay each time you get care. For example, you might pay $25 for a regular doctor visit or $30 when seeing a specialist. Because the amount doesn’t change, it’s easier to plan for common expenses like checkups or prescription refills.
Coinsurance vs. Copay: What's the Difference?
Updated: November 3, 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 often 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 the share of your medical bill you pay after meeting your deductible. For example, if your plan has 20% coinsurance and a procedure costs $5,000, you’d pay about $1,000 while your insurer covers the rest. You’ll keep paying that percentage until you reach your out-of-pocket maximum.
What Is the Difference Between Copay and Coinsurance?
Copays and coinsurance both affect how much you pay for care, but they work differently. A copay is a fixed fee, while coinsurance is a percentage of your bill after meeting your deductible. Here’s how they compare across main 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
Copays and coinsurance apply at different points during your plan year and both affect how much you spend on 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 usually 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 shares costs with you through copays and coinsurance. Copays are flat fees, such as $30 for a doctor visit, while coinsurance means paying a percentage after meeting your deductible. Plans with coinsurance often have lower monthly premiums.
The best choice depends on how often you expect to use your insurance. Compare top-rated health insurance plans to find coverage that fits your needs and budget.
Frequently Asked Questions (FAQs)
We've answered frequently asked questions about the difference between copay and coinsurance to help you understand how they work in your health insurance plan:
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 toward 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 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?
Once you reach your out-of-pocket maximum, you no longer pay copays or coinsurance. Your insurance then covers 100% of covered services for the rest of the plan year. This cap limits how much you spend each year.
For instance, in 2025, it’s about $9,200 for individual coverage or $18,400 for family coverage under ACA plans. This helps protect you from unexpected medical bills.
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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!
He writes about economics and insurance, breaking down complex topics so people know what they're buying.
sources
- Healthcare.gov. "Out-of-pocket maximum/limit." Accessed November 14, 2025.