What is the difference between a deductible, a copay and coinsurance?
CMS counts deductibles, copayments and coinsurance as cost sharing, the part of covered care's cost you pay out of your own pocket.
Arun Verma, co-founder of Triangle · 2026-10-17
This is not clinical evidence and not medical advice. It does not replace your care team. Discuss anything here with your clinician before you act on it.
What is the difference between a deductible, a copay and coinsurance?
HealthCare.gov's glossary describes a deductible as what you pay for covered services before your plan starts to pay, a copay as a fixed amount you pay for a plan-covered service, and coinsurance as a percentage of the cost you pay for each plan-covered service. It adds that after you pay your deductible, you usually pay only a copayment or coinsurance for covered services, and your insurance company pays the rest. CMS says premiums and the cost of care a plan doesn't cover usually aren't counted as cost sharing.
What is a deductible?
You pay the deductible for covered services before your plan starts to pay for them, as HealthCare.gov puts it. CMS describes it as an amount you could owe during a coverage period, usually one year. HealthCare.gov adds that some plans have separate deductibles for certain services, like prescription drugs, and that family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members. HealthCare.gov also says all Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible, and that many plans pay for certain services, like a checkup, before you've met it.
What is a copay?
CMS's fact sheet defines a copay as a fixed amount you pay for a covered service, usually when you receive the service. CMS says the amount can vary by the type of covered service. HealthCare.gov's glossary says copays can vary for different services within the same plan, like drugs, lab tests and visits to specialists. In CMS's example, an office visit has a fixed copay. If you've paid your deductible, you pay the copay, usually at the visit. If you haven't, you pay the full allowed amount for the visit (or the remaining balance until you've paid your annual deductible, whichever is less), and maybe more if the billed amount exceeds the allowed amount. CMS defines the allowed amount as the maximum payment the plan will pay for a covered health care service. HealthCare.gov's glossary defines a copay as an amount you pay after your deductible. On its plan-comparison page, Marketplace plans marked "easy pricing" charge only a copayment for services such as primary care and specialist care, and have "the same out-of-pocket costs and care before deductibles for some services."
What is coinsurance?
CMS's fact sheet defines coinsurance as your share of the costs of a covered service, calculated as a percent of the allowed amount. In its example, coinsurance is 20% of the allowed amount for an office visit. If you've paid your deductible, you pay that 20% and the insurance company pays the rest. If you haven't, you pay the full allowed amount, or the remaining balance until you've paid your yearly deductible, whichever is less. CMS adds that with coinsurance you pay the coinsurance plus any deductibles you owe. HealthCare.gov glosses a copay as a fixed amount and coinsurance as a percentage, like 20%.
How does each one count toward the out-of-pocket maximum?
HealthCare.gov's glossary says your deductible, copays and coinsurance count toward the out-of-pocket maximum for in-network care. That maximum is the most you have to pay for covered services in a plan year, and once you've spent it, your plan pays 100% of the costs of covered benefits. It doesn't include your monthly premiums, anything you spend on services your plan doesn't cover, out-of-network care, or costs above the allowed amount a provider may charge. Plans can differ, though. CMS notes that some plans don't count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward the limit. A fair question for each plan is which of your payments it counts toward the limit.
What does a hypothetical example look like?
A hypothetical plan might have a $1,500 deductible, 20% coinsurance and a $5,000 out-of-pocket maximum. Those are the round numbers in HealthCare.gov's worked example, and they are for illustration only. In February, before the deductible is met, a $125 office visit costs you all $125 and the plan pays $0. After the deductible is met, the same visit costs you $25, which is 20% of $125, and the plan pays $100. Once you've paid $5,000 in total for covered services, the plan pays the full $125 for covered services through the end of the coverage period, usually December 31. The example leaves out prescription drugs, which have separate figures in that plan.
Where do I find each of these for a specific plan?
HealthCare.gov says you can ask your insurance company or group health plan for a copy of the Summary of Benefits and Coverage, or SBC, any time, and that insurance companies and job-based health plans must provide a short, plain-language one. CMS's template for it includes questions like "What is the overall deductible?", "Are there other deductibles for specific services?", "What is the out-of-pocket limit for this plan?" and "What is not included in the out-of-pocket limit?" The template also notes that the copayment and coinsurance costs in its chart are shown after your deductible has been met, if a deductible applies.
How do these relate to the monthly premium?
HealthCare.gov's glossary describes a premium as a monthly amount you pay for coverage whether you get services or not. Generally, plans with lower monthly premiums have higher deductibles, copayments and coinsurance, and plans with higher monthly premiums usually have lower ones. Deductibles, copayments and coinsurance can add a lot to your total yearly costs, sometimes more than a plan's premium, according to HealthCare.gov's plan-comparison page.
What could I ask when comparing plans?
You could ask each plan which services carry a deductible, which carry only a copay, what the coinsurance is after the deductible, and whether your copays count toward the deductible. Copays can differ by service, including specialist visits, so a fair question is what the copay or coinsurance is for the kind of specialist you see. CMS says care from an in-network provider will generally cost less than care from an out-of-network one, so you could also ask whether a given doctor is in the plan's network. Other fair questions are which payments count toward the out-of-pocket limit and whether prescriptions have a separate deductible. No source here says which mix of deductible, copay and coinsurance suits a given household. HealthCare.gov says your actual costs will vary based on the services you use.
Sources
- HealthCare.gov Glossary: Deductible: HealthCare.gov's glossary says a deductible is the amount you pay for covered health care services before your insurance plan starts to pay.
- HealthCare.gov Glossary: Deductible: HealthCare.gov's glossary says that after you pay your deductible, you usually pay only a copayment or coinsurance for covered services, and your insurance company pays the rest.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 1): CMS's fact sheet defines a copayment as a fixed amount you pay for a covered health care service, usually when you receive the service, and says the amount can vary by the type of covered health care service.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 1): CMS's fact sheet defines coinsurance as your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 2): CMS's fact sheet says cost sharing is your share of costs for services a plan covers that you pay out of your own pocket, with copayments, deductibles and coinsurance as examples, and that other costs, including premiums and the cost of care a plan doesn't cover, usually aren't considered cost sharing.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 2): CMS's fact sheet defines a deductible as an amount you could owe during a coverage period (usually one year) for covered health care services before your plan begins to pay.
- HealthCare.gov Glossary: Deductible: HealthCare.gov's glossary says some plans have separate deductibles for certain services, like prescription drugs.
- HealthCare.gov Glossary: Deductible: HealthCare.gov's glossary says family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members.
- HealthCare.gov Glossary: Deductible: HealthCare.gov's glossary says all Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible.
- HealthCare.gov Glossary: Deductible: HealthCare.gov's glossary says many plans pay for certain services, like a checkup, before you've met your deductible.
- HealthCare.gov Glossary: Copayment: HealthCare.gov's glossary says copayments (sometimes called copays) can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 1): CMS's fact sheet gives an example of a doctor's office visit with a copayment: if you've paid your deductible, you pay the copayment, usually at the time of the visit; if you haven't, you pay the full allowed amount for that visit (or the remaining balance until you have paid your annual deductible, whichever is less), and maybe more, if the billed amount exceeds the allowed amount.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 1): CMS's fact sheet says the allowed amount is the maximum payment the plan will pay for a covered health care service.
- HealthCare.gov Glossary: Copayment: HealthCare.gov's glossary defines a copayment as a fixed amount you pay for a covered health care service after you've paid your deductible.
- HealthCare.gov: Your total costs for health care: Premium, deductible & out-of-pocket costs: HealthCare.gov's plan-comparison page says plans marked "easy pricing" have the same out-of-pocket costs and care before deductibles for some services, and that in an "easy pricing" plan you'll only pay a copayment for services including primary care and specialist care.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 1): CMS's fact sheet gives an example of coinsurance of 20% of the allowed amount for an office visit: if you've paid your deductible, you pay that 20% and the insurance company pays the rest; if you haven't, you pay the full allowed amount (or the remaining balance until you have paid your yearly deductible, whichever is less).
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 1): CMS's fact sheet says that with coinsurance you pay the coinsurance plus any deductibles you owe.
- HealthCare.gov Glossary: Deductible: HealthCare.gov's deductible entry glosses a copayment as a fixed amount you pay for a plan-covered service and coinsurance as a percentage of the cost that you pay for each plan-covered service, like 20%.
- HealthCare.gov Glossary: Out-of-pocket maximum/limit: HealthCare.gov's glossary says the out-of-pocket maximum/limit is the most you have to pay for covered services in a plan year.
- HealthCare.gov Glossary: Out-of-pocket maximum/limit: HealthCare.gov's glossary says that after you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
- HealthCare.gov Glossary: Out-of-pocket maximum/limit: HealthCare.gov's glossary says the out-of-pocket limit doesn't include your monthly premiums, anything you spend for services your plan doesn't cover, out-of-network care and services, or costs above the allowed amount for a service that a provider may charge.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 3): CMS's fact sheet says some plans don't count all of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward the out-of-pocket limit.
- HealthCare.gov: Your total costs for health care: Premium, deductible & out-of-pocket costs: HealthCare.gov's worked example describes a Marketplace plan whose deductible is $1,500, coinsurance is 20% and out-of-pocket maximum is $5,000, with coverage starting January 1.
- HealthCare.gov: Your total costs for health care: Premium, deductible & out-of-pocket costs: HealthCare.gov's worked example says that in February, before the deductible is reached, the person pays all costs for most covered health services until they pay $1,500; an office visit costing $125 means they pay $125 and the plan pays $0.
- HealthCare.gov: Your total costs for health care: Premium, deductible & out-of-pocket costs: HealthCare.gov's worked example says that once the deductible is reached, an office visit of $125 costs the person $25 (20% coinsurance, $125 x 20%) and the plan pays $100.
- HealthCare.gov: Your total costs for health care: Premium, deductible & out-of-pocket costs: HealthCare.gov's worked example says that once the person has paid $5,000 in total for covered health services, the plan pays all costs for covered health services through the end of the coverage period (usually December 31), so a $125 office visit costs the person $0 and the plan pays $125.
- HealthCare.gov: Your total costs for health care: Premium, deductible & out-of-pocket costs: HealthCare.gov's worked example notes that the plan has a different deductible, coinsurance and out-of-pocket maximum for prescription drugs and that the example only shows costs for health services.
- HealthCare.gov: Your total costs for health care: Premium, deductible & out-of-pocket costs: HealthCare.gov's plan-comparison page says deductibles, copayments, and coinsurance can add a lot to your total yearly costs, sometimes more than a plan's premium.
- HealthCare.gov: Your total costs for health care: Premium, deductible & out-of-pocket costs: HealthCare.gov's plan-comparison page says your actual costs will vary based on the services you use.
- HealthCare.gov: Summary of Benefits and Coverage: HealthCare.gov says insurance companies and job-based health plans must provide a short, plain-language Summary of Benefits and Coverage (SBC).
- HealthCare.gov: Summary of Benefits and Coverage: HealthCare.gov says you can ask for a copy of the SBC from your insurance company or group health plan any time.
- CMS: Summary of Benefits and Coverage template (PDF, 2024 version) (p. 1): CMS's SBC template includes the questions "What is the overall deductible?", "Are there other deductibles for specific services?", "What is the out-of-pocket limit for this plan?" and "What is not included in the out-of-pocket limit?"
- CMS: Summary of Benefits and Coverage template (PDF, 2024 version) (p. 2): CMS's SBC template says all copayment and coinsurance costs shown in its chart are after your deductible has been met, if a deductible applies.
- HealthCare.gov Glossary: Deductible: HealthCare.gov's glossary describes a premium as a monthly amount you pay for coverage whether you get services or not.
- HealthCare.gov Glossary: Deductible: HealthCare.gov's glossary says that generally, plans with lower monthly premiums have higher deductibles, and plans with higher monthly premiums usually have lower deductibles.
- HealthCare.gov Glossary: Copayment: HealthCare.gov's glossary says that generally, plans with lower monthly premiums have higher copayments, and plans with higher monthly premiums usually have lower copayments.
- HealthCare.gov Glossary: Coinsurance: HealthCare.gov's glossary says that generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.
- CMS: No Surprises: Health insurance terms you should know (fact sheet PDF, 2022) (p. 2): CMS's fact sheet says that, generally, if you get care with an in-network provider or facility, it will cost you less than if you get care with an out-of-network provider or facility.
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