Copays and coinsurance are the two ways you share the cost of care with your plan. A copay is a flat fee, such as $20 for a doctor visit. Coinsurance is a percentage, such as 20% of a hospital bill, and it usually starts after your deductible. Both count toward your yearly out-of-pocket maximum, which caps what you pay.
- A copay stays the same no matter how big the bill is, while coinsurance grows with the bill.
- On a $100 visit with 20% coinsurance, you pay $20 once you meet your deductible.
- For 2027 coverage, ACA plans cap your in-network costs at $12,000 for one person and $24,000 for a family.
- Out-of-network care, premiums and services your plan doesn't cover don't count toward that cap.
- If your income qualifies, a Silver plan with extra savings can lower your copays and coinsurance.
Copay vs coinsurance: the core difference
Both terms describe your share of a covered bill. However, they work in different ways. A copay is a fixed dollar amount, while coinsurance is a percentage of the allowed amount. The allowed amount is the price your plan agreed to pay a network provider.
- Same price each time, such as $20 a visit
- Common for office visits and generic drugs
- Easy to budget for
- For example, 20% of the allowed amount
- Common for hospital stays, surgery and imaging
- Grows as the bill grows
HealthCare.gov uses a simple example. Say the allowed amount for an office visit is $100. With a $20 copay, you pay $20. With 20% coinsurance after your deductible, you also pay $20. So on small bills the two can look alike, but on big bills they don't. Next, look at your own plan summary and find which services use each one.
How copays and coinsurance work with your deductible
Your deductible is what you pay for covered care before the plan starts to share costs. Most plans follow the same order, so it helps to see it step by step. For more detail, read our guide to how deductibles work.
- Preventive care first
Many screenings and vaccines cost $0 in network, even before the deductible.
- Meet the deductible
For most other care, you pay the full allowed amount until you reach it.
- Share each bill
After that, you pay a copay or coinsurance, and the plan pays the rest.
- Hit the yearly cap
Once you reach your out-of-pocket maximum, the plan pays 100% of covered in-network care for the rest of the plan year.
Some copays skip the deductible
Many plans charge a copay for visits or generic drugs from day one. In that case, you pay the copay even before you meet your deductible. Meanwhile, coinsurance on bigger services still waits until the deductible is done. So check the Summary of Benefits and Coverage for the words "deductible does not apply."
Copays and coinsurance with real math
Numbers make this clear. The examples below use one example plan with a $3,000 deductible, 20% coinsurance, a $30 doctor-visit copay and a $9,000 out-of-pocket maximum. These numbers are for illustration only, not a quote.
A small bill: one doctor visit
You see your doctor in February, and the allowed amount is $150. Because this plan uses a copay for visits, you pay $30. Then the plan pays $120. Your $30 also counts toward your $9,000 yearly cap.
A big bill: a $12,000 procedure
This example comes from HealthCare.gov. First, you pay the $3,000 deductible. Next, you pay 20% of the remaining $9,000, which is $1,800. So your total share is $4,800, and the plan pays $7,200.
A huge bill: when the cap kicks in
Now say a hospital stay has a $60,000 allowed amount. Without a cap, you would owe $3,000 plus 20% of $57,000, or $14,400 in all. Instead, you stop at $9,000, because that is your out-of-pocket maximum. After that, the plan pays 100% of covered in-network care until the year ends.
Coinsurance is why big bills can still hurt, and the yearly cap is why they stop.The rule our licensed agents repeat most
A licensed Vivna agent can show what you would pay for a visit, a procedure and a worst-case year on any plan, at no cost to you.
What counts toward your out-of-pocket maximum
Your out-of-pocket maximum is the most you pay in a plan year for covered in-network care. For 2027 coverage, the federal ceiling is $12,000 for one person and $24,000 for a family. Your plan can set a lower cap, though not a higher one.
- Deductible payments for covered in-network care
- Copays for visits, tests and prescriptions
- Coinsurance on covered in-network services
- Monthly premiums
- Out-of-network care and services
- Services your plan doesn't cover
- Charges above the allowed amount that a provider may bill
See our guide to the yearly cap that limits your spending for more. Then write your plan's cap next to its premium, since together they show your worst-case year.
Why the network matters for copays and coinsurance
Your plan's network is the group of doctors, hospitals and pharmacies under contract with it. In network, you pay the normal copays and coinsurance. Out of network, though, costs can climb fast, and some HMO and EPO plans pay nothing except in emergencies.
Also, out-of-network care doesn't count toward your yearly cap. On top of that, a provider outside the network may bill you for the gap between its charge and the allowed amount. That's called balance billing. Compare what in-network and out-of-network care costs, and look up each provider on our Find a Doctor in My Network page.
Read the bill before you pay
After each visit, your plan sends an Explanation of Benefits, or EOB. It shows the allowed amount, what the plan paid and what you owe. So match it to the provider's bill before you pay. Our guide to how medical bills and claims move shows each step.
Prescriptions and drug tiers
Most plans sort covered drugs into tiers on a list called a formulary. Lower tiers, often generics, usually come with a flat copay. Higher tiers, such as specialty drugs, often use coinsurance instead. As a result, one expensive drug can push you toward your yearly cap quickly.
So before you enroll, look up each prescription on every plan's formulary. Note its tier and whether a copay or coinsurance applies. Also ask whether the drug cost counts before or after the deductible.
Which mix of copays and coinsurance fits you?
There is no single best design. Instead, match the plan to how you use care. Lower copays and coinsurance usually mean a higher premium, so weigh both together.
A Bronze plan with low premiums may fit, since preventive care is $0 in network.
Look for copays that apply before the deductible, which are common on Silver and Gold plans.
Compare the out-of-pocket maximum first, because you will likely reach it.
Check a Silver plan with extra savings, which lowers deductibles, copays and coinsurance.
Learn more about Bronze, Silver and Gold tiers. Also, virtual visits often carry a lower copay, so read our guide to getting care by video or phone.
When you compare plans, find three numbers on each summary: the doctor-visit copay, the coinsurance rate and the out-of-pocket maximum. Those three tell you more than the deductible alone. Then ask us to price your top drugs on each plan before you choose.
A 0% coinsurance plan doesn't mean you pay nothing for care. You still pay your deductible and copays, plus your premium every month. Read the full Summary of Benefits and Coverage before you enroll.
For a full yearly estimate, read how to estimate your yearly medical spending. You can also browse our ACA and private medical plan options or call 888-730-6001.
Copays and coinsurance: FAQs
What is the difference between a copay and coinsurance?
A copay is a flat fee, such as $20 for a doctor visit, and it stays the same no matter the bill. Coinsurance is a percentage, such as 20% of the allowed amount, so it grows with the bill. Copays often apply to visits and generic drugs. Meanwhile, coinsurance usually applies to bigger services after you meet your deductible.
Do copays count toward my deductible?
It depends on the plan. On many plans, copays don't count toward the deductible, but they do count toward your out-of-pocket maximum. Other plans apply some copays only after you meet the deductible. So check your Summary of Benefits and Coverage, or ask your agent to explain how your plan handles it.
Is there a limit on how much coinsurance I pay?
Yes. Your coinsurance, copays and deductible all count toward your out-of-pocket maximum for covered in-network care. For 2027 coverage, ACA plans can't set that cap above $12,000 for one person or $24,000 for a family. Once you reach it, the plan pays 100% of covered in-network care for the rest of the year.
Which is better, a copay plan or a coinsurance plan?
Neither is better for everyone. Copays make costs easy to predict, which helps if you see doctors often. Coinsurance plans may charge lower premiums, but big bills cost more. In general, compare total yearly cost, including premiums, and your plan's out-of-pocket maximum.
Can a licensed agent explain my copays and coinsurance?
Yes. A licensed agent can walk through any plan's copays, coinsurance and yearly cap with real examples. Vivna's agents compare plans from 50+ carriers, such as UnitedHealthcare, Ambetter and Oscar, at no cost to you. Call 888-730-6001 Monday through Friday, 9am to 6pm.
Vivna's licensed agents compare plans from 50+ carriers. Call Monday through Friday, 9am to 6pm.
Sources
- HealthCare.gov glossary: Coinsurance
- Copayment, from the HealthCare.gov glossary
- HealthCare.gov glossary: Out-of-pocket maximum/limit
- Preventive health services, from HealthCare.gov
- HealthCare.gov: Cost-sharing reductions
Vivna Insurance is a licensed, independent health insurance agency (NPN 19168641). We are not affiliated with HealthCare.gov or any government agency. Plan availability, networks and benefits vary by state and change over time.