A copayment (copay) is typically a fixed amount you pay for a covered service, such as an office visit. Coinsurance is typically a percentage of the allowed cost for a covered service. The exact rules depend on the plan and the type of care.
Illustrative example
A plan might charge a fixed copay for a primary care visit, while a hospital service may involve coinsurance after a deductible. These examples are only illustrations; do not assume that a real plan uses the same amounts or that all services are treated alike.
Why plan documents matter
Cost-sharing can vary for specialist visits, emergency care, imaging, outpatient procedures, prescriptions, and out-of-network care. Some services may be subject to the deductible; others may have a copay before the deductible. Prescription tiers and specialty drug rules can be especially important.
Questions to ask
- Does the copay apply before or after the deductible?
- What services are subject to coinsurance?
- Does the amount change for in-network vs. out-of-network care?
- How are prescription medications covered?
- Which payments count toward the out-of-pocket maximum?
Review the plan's Summary of Benefits and Coverage and the full policy documents when comparing options.