What is the difference between a copay and coinsurance?

A copay is a fixed amount, such as $30. Coinsurance is a percentage of the allowed amount, such as 20%.

Do I pay a copay before meeting my deductible?

It depends on the plan. Some services have a copay regardless of the deductible. Your summary of benefits says which.

What happens when I reach my out-of-pocket maximum?

HealthCare.gov says your plan then pays 100% of the costs of covered benefits for the rest of the plan year.

DEDUCTIBLE, COPAY, COINSURANCE

Deductible vs copay vs coinsurance: what they mean on your EOB

A deductible is what you pay for covered care before your plan starts to pay; a copay is a fixed amount for a service, such as $30; coinsurance is a percentage of the allowed amount, such as 20%. Your EOB shows how much of each applied to a claim.

Why it’s confusing

All three are “your share”, and an EOB can show more than one on the same line. Plans also use them differently — some services have a copay even before the deductible is met, and many plans pay for certain preventive care before the deductible.

The deductible resets each plan year, so the same visit can cost you very different amounts in January and in October.

How to read it

Deductible: look for “applied to deductible”. That amount is yours, and it brings you closer to meeting the deductible for the year.

Copay: a flat fee for a type of service — a doctor visit, a prescription, a specialist. It is usually the same each time for the same kind of service.

Coinsurance: a percentage of the allowed amount, usually charged after the deductible is met. If your coinsurance is 20%, the plan pays the other 80% of the allowed amount.

All three count towards your out-of-pocket maximum for covered in-network care. Once you reach it, the plan pays 100% of covered services for the rest of the plan year.

HealthCare.gov’s own illustration, laid out as an EOB would show it. Not anyone’s real claim.

On the document	Shows	In plain language
Covered hospital bill	$12,000	The allowed cost of the care.
Deductible	$3,000	You pay all of this first.
Coinsurance (20%)	$1,800	20% of the remaining $9,000.
Your total	$4,800	Deductible plus coinsurance.
Out-of-pocket maximum	$6,850	The most you would pay for covered care that plan year.

If your costs reached $6,850, you would pay only that amount and the plan would pay for covered services for the rest of the plan year.

What it does not mean

That a copay is the whole cost. Other charges — a test done at the same visit, for example — can be billed separately.
That meeting your deductible means everything is free. You usually still pay copays or coinsurance until the out-of-pocket maximum.
That premiums count towards your deductible or out-of-pocket maximum. They don’t.

Where you’ll see it

Insurance EOBs, in separate columns for deductible, copay and coinsurance.
Your plan’s summary of benefits, which lists the amounts that apply to you.

Questions worth asking

Ask your insurer

How much of my deductible have I met this year?
Is this service subject to the deductible, or does it have a copay?
How close am I to my out-of-pocket maximum?

Can’t tell which part of your EOB is deductible and which is coinsurance? Attach it, and Clariti will break it down.

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Common questions

What is the difference between a copay and coinsurance?: A copay is a fixed amount, such as $30. Coinsurance is a percentage of the allowed amount, such as 20%.
Do I pay a copay before meeting my deductible?: It depends on the plan. Some services have a copay regardless of the deductible. Your summary of benefits says which.
What happens when I reach my out-of-pocket maximum?: HealthCare.gov says your plan then pays 100% of the costs of covered benefits for the rest of the plan year.