Coinsurance vs copay

Understanding the difference between coinsurance and a copay can help you manage your health care costs.

What are coinsurance and copays?

You and your health insurance company work together to help share the costs of your health care. Typically, health plans include coinsurance and copayments (or copays). Learn what these terms mean and how they apply to your health insurance costs.

Coinsurance

The sharing of charges by Blue Cross and Blue Shield of North Carolina (Blue Cross NC) and you for covered services, after you have met your benefit period deductible.

This is stated as a percentage. The coinsurance listed is your share of the cost of a covered service.

Copays

The fixed dollar amount you must pay for some covered services at the time you receive them, if this health benefit plan includes copayments.

Copayments (copays) are not credited to the deductible; however, they are credited to the total out-of-pocket limit.

How coinsurance works

Coinsurance helps keep your health care costs more manageable when you need to have expensive procedures or treatments. Instead of paying the full amount for a procedure, you only pay part of it or a percentage of the total. You must meet your deductible for the benefit year before coinsurance starts to help pay.

For this example, let's say you have an 80% / 20% coinsurance plan, and you've met your deductible. Your doctor orders a computed tomography (CT) scan of your lungs. The total cost of a CT scan is $1,000.

Your health insurance will pay 80% ($800), and you'll pay 20% ($200).
You'll continue to pay 20% for other covered procedures until you meet your out-of-pocket maximum for the plan year.
After meeting your out-of-pocket maximum, your health insurance will pay for your covered health care services at 100%.
You'll still have to pay your copays when you're at the doctor's office.

How copays work

Copays help keep your routine or follow-up health care costs affordable. Typically, you'll have a copay each time you go to your primary care provider (PCP), a specialist, or to urgent care.

For this example, let's say you're experiencing back pain and need to go to an in-network urgent care.

The copay for in-network urgent care visits is $100. When you're at urgent care, you must pay the $100 copay at the time of your visit.
A week later, you have a follow-up appointment with your PCP, and your copay is $25. You must pay the copay at the time of your visit.

Other terms you may need to know

Deductible

The amount of money you (the member) must pay for covered services in a benefit period before Blue Cross NC begins to pay for covered services. The deductible does not include coinsurance, charges in excess of the allowed amount, amounts exceeding any maximum, or charges for non-covered services.

For example, a $1,000 deductible means you'll pay the first $1,000 of covered costs before your insurance company starts to pay their part.

Out-of-pocket maximum

The out-of-pocket maximum (or out-of-pocket limit) is the dollar amount you pay for covered services in a benefit period before Blue Cross NC pays 100%. The out-of-pocket limit does not include charges over allowed amounts and charges for non-covered services.

Learn More Health Insurance Terms