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: June 18, 2026
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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?
The right choice depends on how often you use medical care and how well your budget handles variable costs. Predictable copays work better for frequent medical users. Coinsurance plans tend to cost less each month, which benefits people who rarely need care.
You visit doctors frequently for chronic conditions | Copays | Copays keep each visit predictable. A $30 copay is easier to budget than 20% coinsurance on a $200 specialist visit. |
You're healthy and rarely see doctors | Coinsurance | Coinsurance plans have lower monthly premiums, so you spend less overall when you don't need much care. You pay the percentage only when you use services. |
You're planning surgery or have upcoming medical expenses | Copays | Fixed copays make it easier to budget for known expenses. A $50 copay for pre-surgery appointments is more predictable than coinsurance that varies by service cost. |
You want lower monthly premiums | Coinsurance | Coinsurance plans cost less each month, leaving more room in the monthly budget for other expenses. |
You have trouble keeping emergency savings | Copays | Smaller fixed copay amounts are easier to manage than variable coinsurance bills. A $25 copay is a known quantity but a $400 coinsurance payment isn't. |
Bottom Line
Copays are flat fees, like $30 for a doctor visit. Coinsurance means paying a percentage of costs after meeting your deductible. Coinsurance plans tend to have lower monthly premiums. The right fit depends on how often you expect to use your coverage. Compare top-rated health insurance plans to find a plan that matches your budget and care needs.
FAQ
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?
It depends on the plan. Many plans charge copays for doctor visits and prescriptions before the deductible is met, and those copays may or may not count toward the deductible total. Check your plan documents to confirm.
When does coinsurance start?
Coinsurance begins after the deductible is met. Before that point, you pay the full cost of most services, though some plans charge copays for specific types of care regardless of deductible status. Once the deductible is met, the plan pays its share and you pay the coinsurance percentage on remaining costs.
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 (P&C) Insurance Producer in Connecticut, is MoneyGeek's resident insurance expert. He has spent nearly a decade analyzing the market, first at LendingTree and now at MoneyGeek, where he produces original research on hundreds of carriers and millions of rates across auto, home, renters, health and life insurance.
He covers economics and insurance at MoneyGeek, and his work has been featured in The Washington Post, The New York Times and NPR, among other outlets.
Like all MoneyGeek analysts, he draws on independent cost and consumer experience data. No insurance company partnership influences his recommendations.
Fitzpatrick earned his degrees from Johns Hopkins University (M.A. Economics and International Relations) and Boston College (B.A.). His career began in financial risk management at State Street. He's also a five-time “Jeopardy!” champion.
Sources
- Healthcare.gov. "Out-of-pocket maximum/limit." Accessed June 22, 2026.