Deductibles, copays, and coinsurance explained
The three ways your health plan splits costs with you — what each one means, when it applies, and how a single visit can involve all three.
Your share of a medical bill is some combination of three things: a deductible (the amount you pay before the plan helps), copays (flat fees per service), and coinsurance (a percentage you pay after the deductible). Knowing which applies when is the key to predicting what you'll owe.
Deductible
The deductible is the amount you pay out of pocket each plan year before the plan starts sharing costs. If your deductible is $2,000, you pay the first $2,000 of covered care (at the negotiated in-network rate). Once you've spent $2,000, the plan begins paying its share.
Copay
A copay is a flat fee for a specific service — $30 for a primary care visit, $50 for a specialist, $15 for a generic prescription. Many plans charge copays even before the deductible is met for routine services, but charge coinsurance for bigger things like surgery or imaging.
Coinsurance
Coinsurance is a percentage you pay after meeting your deductible. If your plan has 20% coinsurance on a $1,000 MRI, you pay $200 and the plan pays $800 — assuming you've met your deductible. If not, you pay the full $1,000 until the deductible is satisfied.
How they stack on a real visit
- You go to a specialist. The negotiated rate is $400.
- You haven't met your deductible yet. You pay the full $400 — it counts toward the deductible.
- Later in the year, you're back at the same specialist after meeting the deductible. You pay your $50 specialist copay (or 20% coinsurance, depending on the plan).
- Every dollar of deductible, copay, and coinsurance counts toward your out-of-pocket maximum.
FAQ
- Do prescriptions have a separate deductible?
Sometimes. Many plans have a separate Rx deductible (often $100–$300) that resets annually. Tier 1 generics may bypass the Rx deductible entirely.
- If I have a copay, do I still owe coinsurance?
Not on the same service. A given service is either copay-based or coinsurance-based, not both. Your SBC lists which is which.
- Does my employer's HSA contribution reduce my deductible?
No — an HSA contribution doesn't lower the deductible itself, but it gives you tax-free dollars to pay it with.