Is coinsurance the same as a copay?
No. A copay is a fixed dollar amount for a specific service. Coinsurance is a percentage of the cost of a covered service that the employee pays after the deductible is met.
What is behind the short answer.
The short answer is above. These are the details that decide it for a specific plan.
Copay: fixed dollars
Twenty-five dollars for an office visit stays twenty-five dollars whatever the provider bills for the rest of the visit.
Coinsurance: a share
Twenty percent of a 500 dollar charge is 100 dollars. Twenty percent of a 20,000 dollar charge is 4,000 dollars until the out-of-pocket maximum stops it.
Plans use both
A single plan can use copays for routine care and coinsurance for hospital stays and procedures. Each service has its own row.
The practical difference
A copay is predictable. Coinsurance depends on the bill, so it deserves a worked example before an employee chooses.
Same visit, two ways to pay.
Assume the deductible is already met. A copay stays flat while the price of the service changes. Coinsurance moves with it.
Illustrative figures with the deductible already met. Many plans apply copays to office visits and coinsurance to imaging, surgery and hospital care.
We show both on a real bill.
We run a sample bill through each option so the difference between a flat copay and a percentage is a number, not a definition.
Related pages.
The Copay, Explained in Plain Terms
A copay is a fixed dollar amount an employee pays for a specific service, such as a primary care visit or a prescription.
Coinsurance, Explained in Plain Terms
Coinsurance is the percentage of a covered bill the employee pays after the deductible is met.
Health Plan Terms That Sound Alike
Copay and coinsurance, deductible and out-of-pocket maximum, premium and cost of care.
Avoiding Group Health Insurance Plan Confusion
The full guide to helping employees understand their group health plan.
Questions that come up next.
Short answers to the questions employees ask after this one. Each links to its own page.
What is the difference between a deductible and an out-of-pocket maximum?
The deductible is what an employee pays for covered care before the plan starts sharing the cost. The out-of-pocket maximum is the most the employee pays in a year for covered in-network care. One is where sharing begins, the other is where it ends.
Do copays count toward the deductible?
It depends on the plan. On some plans copays count toward the deductible and on others they do not. Copays generally do count toward the out-of-pocket maximum for covered in-network care, but confirm in your plan documents.
Why did we get a bill after a visit that only had a copay?
Because the copay usually covers the visit itself and not everything billed around it. Lab work, imaging, a procedure, a facility fee or an out-of-network provider can each be billed separately.
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General information about group health plan terms, not legal or tax advice. Plan-specific questions belong with the plan documents and the carrier.
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