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Insurance terms seem purposefully confusing sometimes, and it’s easy to want to give up and just pick a random insurance plan that has a low premium. However, that can really come back to haunt you. To help relieve some of your confusion, here’s a breakdown of the differences between a copay and coinsurance, and why you should care.
A copay is a flat fee, not a percentage.
Often times, your copay will vary based on service.
Example: Jenny’s copay for her dermatologist is $40, and her copay for the pharmacy is $20.
Your copay will always be consistent for the same service, no matter how much your doctors bill is.
Example: Sam’s visit to the dentist in March cost $500, and his visit to the dentist in October was $250. Both times his copay was $30.
You will always owe the copay amount, unless you hit your out-of-pocket maximum for the year.
Example: Jeff has a $20 copay for his physical therapist. Even though he’s already hit his $1000 deductible, he will still pay the $20 for his visit. If Jeff’s out-of-pocket maximum is $1500, he would have to pay his $20 copay 25 times before he no longer had to pay a copay.
Your copay will be due at the time of service.
In most cases, your copay fee will not apply towards your deductible.
Coinsurance is a percentage of your medical bills, not a flat fee.
In most insurance plans, you do not pay a coinsurance until after you’ve met your yearly deductible.
Example: Ashley’s gastroenterologist appointment cost $400. She paid her $30 copay at the time of service. Her yearly deductible is $1000, and she has not put any bills toward it yet. This means Ashley will pay the $400 out-of-pocket. She will not owe a coinsurance fee for this appointment, because the full appointment cost went toward her deductible.
Once you hit your deductible, you will be responsible for your coinsurance until you hit your out-of-pocket maximum.
Example: Zach’s deductible is $1000, and he already hit it this year. He recently went to the doctor and his bill was $500. Since he met his deductible, he just owes his coinsurance which is 20%. This means Zach will pay $100 of that $500, and insurance will cover the other $400.
Your coinsurance will be billed to you by your doctor, after the time of service.
Overall, your copay and coinsurance are likely very different. The best course of action when choosing a new insurance plan is to educate yourself on the differences, and make an informed decision so you're aware of what you'll owe when you visit the doctor.