Coinsurance and copays: who pays what, and when
After you meet your deductible, you may still share costs with your insurer through coinsurance or copays. This guide explains the difference, how they stack, and what your out-of-pocket maximum protects you from.
How cost sharing works after your deductible
Once you have met your deductible, most health plans do not simply pay 100% of every covered claim. Instead they use cost sharing — you continue to contribute a portion of each claim, either as a fixed fee (copay) or a percentage (coinsurance), until you hit your out-of-pocket maximum.
The sequence for a typical US health plan is:
What is coinsurance?
Coinsurance is your percentage share of covered costs after meeting the deductible. The most common split in US marketplace plans is 80/20: the insurer pays 80%, you pay 20%.
Example: your plan has a $1,500 deductible and 20% coinsurance. You have a hospital bill of $6,500.
| Stage | Bill portion | You pay | Insurer pays |
|---|---|---|---|
| Deductible | $1,500 | $1,500 | $0 |
| Coinsurance (20%) | $5,000 remaining | $1,000 | $4,000 |
| Total | $6,500 | $2,500 | $4,000 |
The HealthCare.gov coinsurance definition explains how this applies to US marketplace plans. Full details of how deductibles and OOP maximums interact are in our guide to deductibles and out-of-pocket maximums.
What is a copay?
A copay (co-payment) is a fixed fee you pay for a specific healthcare service — typically at the time of the visit. Common copay amounts are $20–$50 for a GP visit, $40–$80 for a specialist, $100–$200 for an emergency room visit.
Copays offer predictability: you know exactly what a visit will cost, regardless of what happens during it. The trade-off is that for expensive services, a fixed copay may be cheaper than coinsurance — but for cheap services, it can be higher.
Copay
- Fixed dollar amount per service
- Predictable cost per visit
- May or may not count toward deductible
- Common for routine/preventive care
Coinsurance
- Percentage of the total claim cost
- Variable — scales with the bill
- Typically applies after deductible
- Common for hospital and specialist costs
How the out-of-pocket maximum protects you
Without a cap, coinsurance could expose you to very large costs in a serious illness year. The out-of-pocket maximum (OOP max) is the most you will pay in a plan year across deductible, copays, and coinsurance. Once reached, the insurer pays 100% of all covered services for the rest of the year.
For 2026, the ACA maximum OOP limits are $9,450 for individuals and $18,900 for families. Plans can set lower limits. See the HealthCare.gov OOP maximum explanation for current figures.
Coinsurance FAQ
Frequently asked questions
- It depends on your plan. In some health plans, copays count towards the deductible and the out-of-pocket maximum. In others, copays are separate and do not count. The HealthCare.gov copay definition explains how US marketplace plans treat copays.
- A copay is a fixed dollar amount you pay per service visit regardless of the total cost. Coinsurance is a percentage of the total cost. A $30 copay for a $150 specialist visit is cheaper than 20% coinsurance ($30 vs $30 — same here, but for a $500 visit, copay is $30 and coinsurance is $100). Copays give predictability; coinsurance scales with the actual cost.
- After it. The typical sequence is: (1) you pay 100% until you meet your deductible; (2) then you pay your coinsurance share (e.g. 20%) for covered services until you reach your out-of-pocket maximum; (3) then the insurer pays 100%. See our guide to deductibles and out-of-pocket maximums for a full worked example.
- The word is used differently in property insurance. In home or commercial property policies, a "coinsurance clause" requires you to insure your property to at least a specified percentage of its replacement value (typically 80–90%). If you are under-insured, the insurer may proportionally reduce your claim payout. The Insurance Information Institute explains property coinsurance in detail.