Do copays count toward my deductible?

It depends on your plan. Some plans count copays toward the deductible, while others do not. Check your Summary of Benefits and Coverage (SBC) document or call your insurance company to confirm.

What is the typical coinsurance rate?

The most common coinsurance rate is 80/20 (insurance pays 80%, you pay 20%). However, rates vary widely — some plans are 70/30 or 60/40, and high-deductible plans may have different coinsurance rates for different types of services.

Copay vs. Coinsurance: What Is the Difference and Which Costs More?

What Is a Copay?

A copay (or copayment) is a fixed dollar amount you pay for a healthcare service at the time of the visit. Common copays include $30 for a primary care visit, $50 for a specialist, and $10-$40 for a prescription. Copays are the same regardless of the total cost of the service. Some plans charge copays before you meet your deductible, while others only apply copays after the deductible is met.

What Is Coinsurance?

Coinsurance is a percentage of the total allowed cost that you pay after meeting your deductible. If your plan has 20% coinsurance, you pay 20% and insurance pays 80%. Unlike copays, coinsurance amounts vary based on the cost of the service — 20% of a $500 lab test is $100, but 20% of a $50,000 surgery is $10,000. Coinsurance typically applies after the deductible until you reach your out-of-pocket maximum.

How They Work Together

Many plans use both copays and coinsurance. For example, you might pay a $30 copay for office visits and 20% coinsurance for hospital stays. The structure varies by plan — some use copays only, some use coinsurance only, and many use a combination. Check your plan's Summary of Benefits and Coverage (SBC) for the specific cost-sharing structure.

Which Costs More?

For routine, low-cost services, copays and coinsurance often result in similar out-of-pocket costs. For expensive services (surgery, hospital stays, specialty drugs), coinsurance can cost significantly more because it is a percentage of a much larger number. Plans with lower monthly premiums often have higher coinsurance rates, meaning you save on premiums but pay more when you actually use healthcare.

The Out-of-Pocket Maximum Safety Net

Regardless of whether your plan uses copays, coinsurance, or both, all ACA-compliant plans have an out-of-pocket maximum — the most you can spend on covered in-network services in a year. For 2026, the maximum out-of-pocket limit is $9,450 for individuals and $18,900 for families. Once you reach this limit, insurance covers 100% of covered services for the rest of the plan year.