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A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service.

Your health plan determines what your copay is for different types of services, and when you have one. You may have a copay before you’ve finished paying toward your deductible. You may also have a copay after you pay your deductible, and when you owe coinsurance.

Your deductible is the amount you pay for health care services before your health insurance begins to pay. If your health plan’s deductible is $1,500, you’ll pay 100% of eligible health care expenses until the bills total $1,500. After that, you share the cost with your health plan by paying coinsurance

How deductibles affect your premium

Different things affect your premium. That’s the amount you pay each month to maintain your health care coverage. How many people are on your plan, the type of health plan and network size all lower or raise your premium. So does your health plan’s deductible. 
 
In most cases, the higher a health plan’s deductible, the lower the premium. When you’re willing to pay more up front when you need care, you save on what you pay each month. 

Some people would rather have a smaller premium and pay more up front for care as they go. It can make your expenses less predictable, since you never know when you might end up with a lot of medical bills.

The lower a health plan’s deductible, the higher the premium. You’ll pay more each month, but your health plan will start sharing the costs sooner because you’ll reach your deductible faster. 

Some people like knowing that when they need their insurance, they won’t have to come up with a large sum of money before their health plan starts helping with the cost. So, they’d rather have a higher premium, but a lower deductible. 

Coinsurance is your share of the costs of a health care service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you've paid your health plan's deductible.

You’ve paid $1,500 in health care expenses and met your deductible. When you go to the doctor, instead of paying all costs, you and your health plan share the cost. For example, your health plan pays 70%. The 30% you pay is your coinsurance.

You share the cost of your care with your health insurance company when you pay your deductible, coinsurance and copays. But did you know there’s a limit to how much you pay? It’s called an out-of-pocket max, or maximum. It’s the most you’ll have to pay during a policy period, usually a year, for health care services.

What you pay toward your health plan’s deductible, coinsurance and copays are all applied to your out-of-pocket max.

Once you reach your out-of-pocket max, your health plan pays 100% of the allowed amount for covered services.

If your plan covers more than one person, you may have a family out-of-pocket max and individual out-of-pocket maximum. That means:

When the deductible, coinsurance and copays for one person reach the individual maximum, your health plan then pays 100% of the allowed amount for that person.

When what you’ve paid toward individual maximums adds up to your family out-of-pocket max, your plan will pay 100% of the allowed amount for health care services for everyone on the health plan. 

What doesn’t go toward your out-of-pocket max?

• Your monthly payment, or premium
• Out-of-pocket maximums for dental plans 
• Health care services that aren’t included in your health plan

Out-of-pocket maximums for dental plans also limit what you pay in deductible, coinsurance and copays. But, dental plans usually only have an out-of-pocket max for members age 19 and younger.