Copays, deductibles, and coinsurance are all out-of-pocket expenses that represent the portion that an individual is required to pay either before or after health insurance covers additional costs. Knowing how these expenses work can help you make informed decisions when selecting a plan and better manage your healthcare budget.
A copay is a fixed fee that you pay for specific healthcare services, as determined by your insurance plan. Different services often have varying copay amounts. For instance:
One of the advantages of copay plans is predictability—you know the cost of your visit upfront. Copays typically apply to office visits, prescriptions, and urgent care.
A deductible is the total amount you must pay for healthcare services before your insurance starts contributing. Once the deductible is met, your insurance will cover a portion or all of the remaining costs, depending on your plan’s terms.
For example, let’s say your annual deductible is $3,000. If you need medical services such as hospital stays, surgeries, lab tests, or imaging, you will pay 100% of the costs until the total reaches $3,000. Once the deductible is met, your insurance coverage kicks in, potentially covering additional expenses entirely or splitting costs with you through coinsurance (e.g., 80/20 or 50/50). This only applies to in-network care. If there are dependents on your insurance plan, there could be both individual and family deductibles. See this article for more information about family deductible plans.
Preventive services such as annual check-ups are often covered without needing to meet the deductible. Plans with lower deductibles typically have higher monthly premiums, while plans with higher deductibles offer lower premiums.
Coinsurance is the percentage of healthcare costs you pay after meeting your deductible. The remaining percentage is covered by your insurance.
For example:
An out-of-pocket maximum is the most you’d have to pay within a plan year for healthcare services. This amount includes the sum of copays, deductibles, and coinsurance payments for in-network care. Once you’ve reached the out-of-pocket maximum, your insurance provider covers 100% of your healthcare costs for the rest of the plan year.
However, it’s important to note what’s NOT included in the out-of-pocket maximum:
Your insurance premiums.
Money spent on services NOT covered within your health insurance plan.
Out-of-network services.
Costs above the allowed amount for a service that a provider may charge.
This means you may still incur additional costs if you utilize services that fall into these categories. For instance, if you pay $2,000 for an elective surgery not covered by your insurance, this amount will not count toward your maximum.
Out-of-pocket maximums make it easier to budget your healthcare expenses, but it’s essential to understand what is and isn’t covered under your plan to avoid unexpected charges.
Let’s break it down with an example:
Scenario:
You visit your primary care doctor for an annual check-up, which is free as it’s a preventive service. During your visit, you mention symptoms that lead your doctor to refer you to a specialist. The specialist visit costs you a $50 copay. After evaluation, you are diagnosed with tonsillitis and require a tonsillectomy, which costs $8,000.
Breakdown of costs:
First, you pay $2,500 to meet your deductible. Afterward, your coinsurance applies to the remaining balance of $5,500. With a 50/50 coinsurance plan, you pay $2,500, and your insurance covers the other $2,500. At this point, you’ve reached your out-of-pocket maximum of $5,000.
Total you pay: $2,500 (deductible) + $2,500 (coinsurance) = $5,000.
Remaining surgery cost ($500): Paid entirely by insurance.
For the rest of the plan year, your insurance covers 100% of in-network expenses. However, costs for services not included in your plan (e.g., out-of-network care or uncovered services) remain your responsibility.
Understanding the relationship between deductibles, coinsurance, and out-of-pocket maximums can help you save money. Here are some tips:
Plan major procedures strategically: If you’ve already met your out-of-pocket maximum for the year, schedule elective surgeries or treatments before the plan year resets.
Review your plan’s preventive services: Many plans offer no-cost preventive care, helping you catch potential health issues early.
Stay in-network: Out-of-network services can result in significantly higher costs, often not covered by your insurance.
Understand your plan’s tiers: Plans with higher premiums may have lower deductibles and coinsurance, which could be beneficial if you anticipate needing frequent medical care.
Additional Resources
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