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Deductible, copay, and coinsurance: what you actually pay

A plain-English guide to the four terms that decide your share of a medical bill — with a worked example.

The four things that decide what you pay

Even with good insurance, you pay part of most medical bills. Four terms determine how much — and they trip up almost everyone. Here's what each one actually means.

Deductible

The amount you pay before your insurance starts paying. If your deductible is $2,000, you cover the first $2,000 of covered care yourself. Crucially, until you hit it you usually pay the full negotiated price of each service — which is exactly why knowing that price matters.

Copay

A flat fee for a specific service — say $30 for a doctor's visit or $15 for a prescription. Copays often apply even before you meet your deductible, depending on your plan.

Coinsurance

A percentage you pay after your deductible is met. With 20% coinsurance, on a $1,000 service your plan pays $800 and you pay $200 — until you reach your out-of-pocket maximum.

Out-of-pocket maximum

The most you'll pay in a year for covered, in-network care. Once your deductible, copays, and coinsurance add up to this cap, your insurance pays 100% of covered care for the rest of the year. This is the number that protects you from catastrophe.

How it stacks up: a worked example

Say you have a $2,000 deductible, 20% coinsurance, and a $7,000 out-of-pocket max, and you need a procedure with a negotiated price of $10,000:

You pay the first $2,000 (your deductible).
Of the remaining $8,000, you pay 20% = $1,600 (coinsurance); your plan pays $6,400.
Your total: $3,600 — and since that's under your $7,000 cap, you owe all of it.

Two more such procedures that year and you'd hit the $7,000 cap, after which you'd owe nothing more.

Why the hospital price still matters when you're insured

Early in the year, before you've met your deductible, you pay the full negotiated price of each service — so the price is your cost. And the negotiated price varies wildly between hospitals for the same care. Comparing before non-emergency treatment can lower what counts against your deductible. Cash vs. negotiated price →

In-network vs. out-of-network

These rules apply to in-network care. Out-of-network providers can charge more and may not count toward your in-network out-of-pocket max. For most surprise out-of-network bills you're now protected. The No Surprises Act →

Frequently asked questions

What's the difference between a copay and coinsurance?

A copay is a flat fee for a service (like $30 for a visit). Coinsurance is a percentage you pay after meeting your deductible (like 20% of the cost). Copays often apply even before the deductible is met; coinsurance generally applies after.

Do I pay the full price before I meet my deductible?

For most services, yes — until you've met your deductible you pay the full negotiated price of each covered service. That's why comparing hospital prices matters even when you're insured: early in the year, the price is your cost.

What happens after I hit my out-of-pocket maximum?

Once your deductible, copays, and coinsurance for the year add up to your out-of-pocket maximum, your insurance pays 100% of covered, in-network care for the rest of the year. It's the cap that protects you from catastrophic costs.

Does coinsurance apply before or after the deductible?

After. You first pay your deductible in full, then coinsurance (your percentage share) applies to additional covered care until you reach your out-of-pocket maximum.

Prices in this guide are as of June 2026 and link to the live page for current figures. Published data is for comparison, not a quote — always confirm with the hospital. Spotted something off? Submit a correction.