A copay is a fixed fee you pay each time you get care. For example, a plan may charge $25 for a primary care visit and $30 to see a specialist, though the exact amounts are set by your plan. Fixed amounts make it easier to budget for routine expenses like checkups or prescription refills.
Coinsurance vs. Copay: What's the Difference?
Updated: October 27, 2026
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Key Takeaways
A copay is a flat fee per visit. Coinsurance is a percentage of the bill that starts after you meet your deductible.
Most plans use both: copays for doctor visits and prescriptions, and coinsurance for surgery, hospital stays and imaging.
Plans with lower premiums usually charge more when you get care, through a higher deductible, copay or coinsurance.
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 covers four of every five dollars in costs after your deductible and a procedure costs $5,000, you'd pay $1,000 and your insurer covers the remaining $4,000. You'll keep paying your coinsurance share until you reach your out-of-pocket maximum. That cap is the most you'll spend on covered care in a year before your plan covers everything.
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. Coinsurance is a percentage of your bill after meeting your deductible.
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 | $20–50 for doctor visits | 20–30% 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) |
Is It Better to Have Copay or Coinsurance?
Most plans use copays and coinsurance together, so what you're choosing is how a plan charges for routine care. A copay plan charges a flat fee for doctor visits and prescriptions. A coinsurance plan charges full price for those visits until you meet your deductible, then a percentage of each bill.
Coinsurance plans usually cost less each month because the plan pays a smaller share of your care. Those savings have to cover what you pay per visit. A $200 specialist visit costs $30 with a copay. Under a coinsurance plan, the same visit costs the full $200 before your deductible and $40 at 20% coinsurance after it.
You visit doctors frequently for chronic conditions | Copay plan | A $30 specialist copay compares with $200 at full price before your deductible, or $40 at 20% coinsurance after it. |
You’re healthy and rarely see doctors | Coinsurance plan | Coinsurance plans have lower monthly premiums, so you spend less overall when you rarely need care. Preventive care like annual checkups is free under either plan. |
You’re planning surgery or have upcoming medical expenses | Lower deductible and out-of-pocket maximum | Surgery falls under your deductible and coinsurance whether or not your plan uses copays for visits. At 20% coinsurance, a $5,000 procedure costs you $1,000 after your deductible. Your out-of-pocket maximum caps the year’s total, so compare that number first. |
You want lower monthly premiums | Coinsurance plan | The plan pays a smaller share of your care until you meet your deductible, which keeps the premium lower. Expect to pay full price for doctor visits until then. |
You have trouble keeping emergency savings | Copay plan | No change to the Why text. |
What Is Cost Sharing in Health Insurance?
Cost sharing is how you and your insurer divide the cost of medical care. Health plans use four tools (deductible, copays, coinsurance and out-of-pocket maximum) to determine your portion of each bill, and each applies at a different point in your plan year.
Each service costs you the most early in the year, before you've met your deductible. After that, copays and coinsurance apply based on the type of care. Your out-of-pocket maximum caps the total, and once you reach it, your plan covers all eligible costs.
- Deductible: What you pay before your plan starts sharing most costs
- Copay: A flat dollar amount per visit
- Coinsurance: Your share of costs after meeting your deductible
- Out-of-pocket maximum: Your annual cap on covered care costs
How Coinsurance and Copay Work Together
Copays and coinsurance apply at different stages of your plan year, and both affect your total spending. Most plans use all four cost-sharing tools (deductible, copay, coinsurance and out-of-pocket maximum) at different points, so how much you pay changes as the year progresses.
Before Meeting Your DeductibleYour deductible is the annual amount you pay before your plan starts sharing costs. During this phase, you pay full price for most services. Preventive care like annual checkups and vaccinations stays free under the Affordable Care Act (ACA). Some plans charge copays for primary care before the deductible is met, so you pay a flat cost for routine appointments instead of the full visit price.
After Meeting Your DeductibleYour plan starts sharing most costs once you meet your deductible. You'll pay copays for services like doctor visits or prescriptions. Coinsurance applies to larger expenses like surgery and hospital stays. On the same day, you may pay a $30 copay to see your doctor and a separate coinsurance charge for an MRI.
With Your Out-of-Pocket MaximumYour out-of-pocket maximum is the most you’ll pay for covered care in a plan year. Once you reach it, you stop paying copays and coinsurance for the rest of the year. For Marketplace plans, the limit is $10,600 for individual coverage and $21,200 for family coverage in 2026. The standard limit rises to $12,000 and $24,000 in 2027. Starting in 2027, some Bronze plans can set a higher limit, so check the limit listed on any Bronze plan you compare.
Bottom Line
A copay is a flat fee for each visit. Coinsurance is a share of costs you pay once your deductible is met. Most plans use both, so compare how each plan charges for the care you use most.
Plans that charge full price for visits until the deductible usually have lower premiums. If you rarely need care beyond free preventive visits, the lower premium usually costs less overall. If you see doctors regularly or fill ongoing prescriptions, flat copays keep each visit predictable.
For planned surgery, the copay matters little. Your deductible, coinsurance rate and out-of-pocket maximum set the bill. For individual Marketplace coverage, the out-of-pocket maximum can’t exceed $10,600 in 2026. The standard 2027 limit is $12,000, though some Bronze plans can go higher starting that year.
Frequently Asked Questions
Not for the same service. Copays apply to services like doctor visits, and coinsurance applies to larger services like hospital stays or surgeries. You can pay both on the same day. A visit to your doctor comes with a copay; an MRI during the same visit falls under coinsurance.
Most plans use both for different types of care. You pay a copay when you see your doctor or pick up a prescription. Coinsurance applies to larger services like surgery or imaging. You can pay both on the same date, such as a doctor visit and an MRI, with each charge covering a different service.
It depends on your plan design. Some plans charge copays for doctor visits and prescriptions before the deductible is met. Whether those copays count toward the deductible total varies. Plans that count copays toward the deductible help you reach it sooner. Your plan's Summary of Benefits and Coverage document confirms which rule applies to you.
Coinsurance starts once you meet your deductible. Before that point, you pay the full cost of most services, though some plans charge copays for doctor visits and prescriptions regardless of deductible status. Once you meet the deductible, the plan pays its share and you pay the coinsurance portion on each remaining covered service.
Once you reach your out-of-pocket maximum, you no longer pay copays or coinsurance. Your plan then covers all remaining eligible costs for the rest of the plan year. For Marketplace plans, the limit is $10,600 for individual coverage and $21,200 for family coverage in 2026. The standard limit rises to $12,000 and $24,000 in 2027, though some Bronze plans can set a higher limit starting that year. These limits reset at the start of each new plan year.
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About Mark Fitzpatrick
Mark Fitzpatrick is a licensed Property and Casualty (P&C) Insurance Producer and MoneyGeek's resident expert in insurance and economics. In nearly a decade covering the insurance market at LendingTree and MoneyGeek, he's analyzed hundreds of carriers and millions of rates across auto, home, renters, health and life insurance.
His work has appeared in The Washington Post, The New York Times and NPR. He draws on independent cost and consumer experience data, and no insurance company partnerships affect his recommendations.
Mark studied at Boston College and later earned a master's in economics and international relations from Johns Hopkins University. He worked in financial risk management at State Street before joining MoneyGeek. He's also a five-time “Jeopardy!” champion.
Sources
- HealthCare.gov. "Copayment." Accessed November 4, 2026.
- HealthCare.gov. "Coinsurance." Accessed November 4, 2026.
- HealthCare.gov. " Health plan categories: Bronze, Silver, Gold & Platinum." Accessed November 4, 2026.
- HealthCare.gov. "Out-of-pocket maximum/limit." Accessed November 4, 2026.
- CMS.gov. "HHS Notice of Benefit and Payment Parameters for 2027 Final Rule." Accessed November 4, 2026.