How do deductibles, coinsurance and copays work?
Who is this for?
This information will help you if you’re shopping for health insurance and have questions about how it works.
When both you and your health insurance company pay part of your medical expense, it’s called cost sharing. Deductibles, coinsurance and copays are all examples. Understanding how they work will help you know when and how much you have to pay for care.
- A deductible is the amount you pay for health care services before your health insurance begins to pay.
Let’s say your plan’s deductible is $1,500. That means for most services, you’ll pay 100 percent of your medical and pharmacy bills until the amount you pay reaches $1,500. After that, you share the cost with your plan by paying coinsurance and copays.
- Coinsurance is your share of the costs of a health care service. It’s usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you’ve paid your plan’s deductible.
Here’s how it works. Lisa has allergies, so she sees a doctor regularly. She just paid her $1,500 deductible. Now her plan will cover 70 percent of the cost of her allergy shots. Lisa pays the other 30 percent; that’s her coinsurance. If her treatment costs $150, her plan will pay $105 and she’ll pay $45.
If Lisa has a PPO plan, she has the option to see any doctor she wants. If she goes to an out-of-network doctor, her plan will still share the cost, but her percentage of coinsurance will be higher. And, if the medical service she gets is more than what her plan would pay for an in-network doctor, she’ll have to pay the difference.
Learn more about the difference between in-network and out-of-network benefits.
- A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.
For example, a doctor’s office visit might have a copay of $30. The copay for an emergency room visit will usually cost more, such as $250. For some services, you may have both a copay and coinsurance.
What does this mean for me?
When choosing a plan, think about how much you use your insurance and how much protection you want against unpredictable expenses. Then look at the plan’s deductible, coinsurance and copays and find what works best for you. Here are a few things to consider.
- Deductible: A plan with a high deductible will have cheaper monthly payments. But you’ll pay a lot upfront when you need care. You can also look for plans that cover some services before you pay your deductible.
- Coinsurance: Typically, the lower a plan’s monthly payments, the more you’ll pay in coinsurance.
- Copays: If you visit your doctor or pharmacy often, you might want to choose a plan that has a low copay for office visits and prescriptions.