Copay or Coinsurance — What’s the Difference?

Copay or Coinsurance — What’s the Difference?

While premiums go toward the total cost of the care you receive, health care costs add up to more than your premiums cover.

To keep premiums lower, plans typically have a deductible that you pay if you get care. A deductible is the amount you have to pay before the health plan starts paying for some of your covered services. For instance, if your deductible is $1,000, your plan won't cover some services until you've paid $1,000.

In addition to your monthly premium and deductible, copays and coinsurance are the other out-of-pocket amounts you may pay when you get care.

Copay

A copay is a fixed price you usually pay when you get care.

The amount of the copay can change depending on where you go. You may have a $30 copay for a primary care doctor visit. A specialist visit may take a $50 copay. A trip to the ER could be as much as a $200 copay. Take a look at your member ID card. It will have a list of your copays for different types of visits.

There are two times you may not have a copay. Your health plan covers preventive screenings and services at no cost to you as long as you visit a doctor in your plan’s provider network.*

The other time is after you’ve met your deductible.

If you pay more than your copay, it is likely because both a copay and coinsurance are required.

Coinsurance

Coinsurance is a percentage of the costs of a covered health care service. It is the part of the cost of a service that you pay. Your health plan pays the rest (after you've paid your deductible).

For example, if you have a 40 percent coinsurance for a test or procedure provided during a specialist visit that costs $100, your part is $40.

How are copays and coinsurance used together?
In addition to your deductible amount (if it isn’t paid yet for the year), you may have both a copay and coinsurance if more than one kind of service is part of a visit.

Say you go to the dermatologist for a regular checkup. You’ll pay a copay for your visit. And if while you’re there you have a suspicious mole removed, you may also pay coinsurance for the procedure the doctor performed.

It can be hard to know how to use your health plan so you get the most out of it. Understanding everything you can is the key to saving money and not being surprised when you go to check out or get a bill in the mail.

If you have questions about your coverage before, during or after you use it, check your benefits booklet or log in to your Blue Access for MembersSM (BAMSM) account. Or you can call the customer service number on your member ID card to speak with a customer service advocate.

Comparison Shop for Your Health Care Services

Do you know that the cost for some health care services and procedures can vary a lot, even for the same service in the same area? Because coinsurance is a percent of the cost of a procedure, you may be able to save money by comparison shopping for some procedures. Learn more about how to Comparison Shop for Your Health Care Services.

*Non-grandfathered health plans are required by the Affordable Care Act to provide coverage for preventive care services without cost-sharing only when the member uses a network provider. You may have to pay all or part of the cost of preventive care if your health plan is grandfathered. To find out if your plan is grandfathered or non-grandfathered, call the Customer Service number listed on your member ID card.

Originally published 2/2/2016; Revised 2019, 2022

Anonymous