Copays, Deductibles, Coinsurance

While there is some difference across insurance companies, these definitions are shared by the majority of companies to describe the mix of which costs are paid by you, and which are paid by your insurance company.

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A Copay is a predetermined fee that you pay per visit. The amount can be different for different kinds of visits. For instance, your copay for a provider's office visit will likely be different from your copay at an emergency room, or a specialty clinic.

The copay does not usually count toward your deductible or your out-of-pocket maximum.

Copays don't typically apply to labs or x-rays.

 

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A deductible is the dollar amount your insurance company says you must pay out-of-pocket each year before the insurance company begins paying for medical services provided you.

Some plans don’t apply primary care visits towards the deductible, meaning you only pay the copay. But, if your insurance company does apply primary care to your deductible, you will receive a bill for the entire amount of the charges allowed by your insurance, until you have paid your full deductible.

Check your plan’s benefits for what is and what is not applied towards your deductible.

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There is no lexicon of insurance terms agreed-upon by all insurance companies, and insurance companies use different terms for similar topics, but coinsurance is usually a percentage that the insurance company will pay after your deductible is met.

It may also be applicable to visits that are not applied to your deductible, but still are not paid at 100% by your insurance company. For example, when your insurance company pays 80% and you pay 20% of allowable charges.

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