What It Means
A copay, short for copayment, is a set dollar amount you pay for a covered health care service, such as $20 for an office visit. HealthCare.gov describes it as what you pay once you've met your deductibleInsurance deductibleThe part of a covered loss you pay yourself before your home, renters or auto insurance pays the rest, set as a dollar amount or a percentage. See more, and one plan can set different copays for different services, like prescriptions, lab tests and specialist visits. Copays for covered in-networkIn-networkDescribes a doctor, hospital or other provider that has a contract with your health plan, so you usually pay less for covered care than you would outside the network. See more care count toward your plan's out-of-pocket maximumOut-of-pocket maximumThe most you pay in a plan year for covered in-network care through deductibles, copays and coinsurance, after which the plan pays covered benefits in full. See more.
Try It: Add Up a Year of Copays
Enter your plan's copays and how often you expect each service in a year. The starting numbers are examples.
Copays count toward the out-of-pocket maximum, along with the deductible and coinsurance you pay.
How People Say It
- "It's a $30 copay for the specialist."
- "Bring your card, the copay's due at check-in."
- "My copay went up for the same prescription."
The Breakdown
Worked example. One adult's expected year, with example copays:
| Service | Copay | Times a year | Total |
|---|---|---|---|
| Primary care visit | $25 | 4 | $100 |
| Specialist visit | $50 | 2 | $100 |
| Prescription fill | $15 | 12 | $180 |
| Total | $380 |
That's about $31.67 a month on average, and for covered in-network care all $380 counts toward the plan's out-of-pocket maximum.
Copay, coinsurance and deductible side by side
| Copay | CoinsuranceCoinsuranceYour share of the cost of a covered health care service, set as a percentage such as 20%, that you pay after meeting your deductible. See more | Deductible | |
|---|---|---|---|
| What it is | A fixed dollar amount per service | A percentage of the covered cost | What you pay before the plan starts sharing |
| Example | $20 a visit | 20% of the bill | The first $2,000 of covered care |
| Counts toward the out-of-pocket maximum for covered in-network care | Yes | Yes | Yes |
What the result means. Copays are predictable, so a year of regular visits and refills can be added up ahead of time. A bill with coinsurance moves with the size of the bill instead.
Good to Know
The HealthCare.gov glossary is the plain-language reference for these terms. It lists deductibles, copays and coinsurance for covered in-network care as the spending that counts toward the out-of-pocket maximum, after which the plan pays in full for covered benefitsBenefits packageEverything an employer offers on top of wages, such as health insurance, paid leave and a retirement plan, which can be worth thousands of dollars a year. See more. Many plans pay for some services, such as a checkup, before the deductible is met, so check how your plan handles each service you use.
FAQ
What's the difference between a copay and coinsurance?
A copay stays the same fixed dollar amount, such as $20 a visit. With coinsurance you pay a percentage of the covered cost, like 20%, so a bigger bill means a bigger share for you.
Do copays count toward the out-of-pocket maximum?
Yes. HealthCare.gov counts copays, together with deductibles and coinsurance for covered in-network care, toward the out-of-pocket maximum.
Why are my copays different for different visits?
A plan can set a separate copay for each kind of service, so a specialist visit, a lab test and a prescription may each carry a different fixed amount. Your plan's documents list them.
Do It in Buhata
Budget, repeating entries
Set up each regular prescription copay as a repeating expense in Budget so the monthly cost shows up before it's charged.
Open BuhataRelated Terms and Categories
- Coinsurance
Your share of the cost of a covered health care service, set as a percentage such as 20%, that you pay after meeting your deductible.
- Health insurance deductible
What you pay on your own for covered health care before your health insurance plan begins sharing the cost.
- Out-of-pocket maximum
The most you pay in a plan year for covered in-network care through deductibles, copays and coinsurance, after which the plan pays covered benefits in full.
- Health insurance
A plan you pay a premium for that covers part of your medical costs, while you pay your own share through a deductible, copays and coinsurance.
- In-network
Describes a doctor, hospital or other provider that has a contract with your health plan, so you usually pay less for covered care than you would outside the network.
- Flexible spending account
An account through your employer that lets you set aside pretax pay for eligible medical costs; for 2026 you can put in up to $3,400, mostly spent within the plan year.
Sources
HealthCare.gov Glossary, "Copayment"; HealthCare.gov Glossary, "Coinsurance"; HealthCare.gov Glossary, "Deductible"; HealthCare.gov Glossary, "Out-of-pocket maximum/limit"
- www.healthcare.gov/glossary/co-payment
- www.healthcare.gov/glossary/co-insurance
- www.healthcare.gov/glossary/deductible
- www.healthcare.gov/glossary/out-of-pocket-maximum-limit
Last updated .