Deductibles, Copays, and Coinsurance: What You Actually Pay

Health insurance has its own vocabulary, and the terms determine exactly what comes out of your pocket. Once you see how deductible, copay, coinsurance, and out-of-pocket maximum fit together, a plan's summary stops being a puzzle.

Deductible

The deductible is the amount you pay for covered care before insurance starts sharing the cost. With a $2,000 deductible, you pay the first $2,000 of covered services yourself. Some services, like preventive care, are often covered before you meet it.

Copay

A copay is a flat fee for a specific service, like $30 for a doctor visit or $15 for a prescription. Copays may apply even before you hit your deductible, depending on the plan, and they do not change based on the total bill.

Coinsurance

After you meet the deductible, you usually still share costs through coinsurance, a percentage. With 20% coinsurance, insurance pays 80% of covered costs and you pay 20%. This continues until you reach your out-of-pocket maximum.

Out-of-pocket maximum

This is the ceiling on what you pay in a year for covered, in-network care. Once your deductible, copays, and coinsurance add up to this number, insurance pays 100% of covered costs for the rest of the year. It is the single most important number for worst-case protection.

How they fit together: an example

Imagine a $2,000 deductible, 20% coinsurance, and a $6,000 out-of-pocket max. A $10,000 surgery: you pay the first $2,000 (deductible), then 20% of the remaining $8,000 ($1,600), for $3,600 total, which is under your max. If costs kept climbing, you would never pay more than $6,000 for the year.

See your likely costs under a plan with our out-of-pocket cost estimator.