Difference between Coinsurance, Copay and Deductible in Health Insurance

What is Copay, Coinsurance and Deductible in medical billing?

Copay, Coinsurance and Deductible are important terms in health insurance that most people are not familiar with. Let us take a look at these terms in this post to understand their differences.

Understanding all the terms and jargons related to health insurance and how they affect your policy may not be possible for the common man. Some such tricky terms like copay, deductible and coinsurance are such that many people do not know much about them, especially people who do not have enough experience and knowledge of insurance.  So, let’s see the difference between copay, deductible and coinsurance to understand their meaning better.

What is Copay in Health Insurance?

Copay is the short form of Copayment. Copay meaning in health insurance is a sum of money that the policyholder must pay while claiming for a healthcare service such as doctor visits, prescriptions, urgent care, emergency room visit etc. The copay contribution is a fixed amount that is predetermined at the time of buying the policy.

For instance, let’s say the copay fixed is 10%. Now, let’s say the cost of health service claimed is INR 10,000. So, the insured has to pay 10% of INR 10,000, which is INR 1000 to your insurer, while the rest INR 9000 would be paid by the insurer.

Does Copay Always Exist?

No, they are not necessarily used by all health insurance plans. Depending on the coverage offered and the particular plan, it may have deductibles or coinsurances along with copays.  On the other hand, some specific conditions and services may be settled without any out-of-pocket charges being levied on the insured.

What Do You Understand by Deductible?

Deductible is a fixed amount of money paid by the insured before his/her health insurance policy starts paying for claims. So, here, the insured has to pay a fixed amount before they start receiving insurance coverage. Deductible amounts might vary depending on individual and family floater coverage. However, having a considerably small deductible is common in most health insurance plans.

For example, if the deductible amount on your health plan is INR 5000, you must pay that amount first before expecting contributions from the insurance company for your claims.

What is Coinsurance in Medical Billing?

Coinsurance meaning in health insurance is a portion of your healthcare bill that is settled by the policyholder after meeting their deductibles, while the rest is settled by the insurer. So, coinsurance in medical billing implies that the policyholder and the insurer share a particular medical expense. For instance, if your plan offers an 80:20 ratio of coinsurance, it means that the policyholder pays 20% of the bill amount, while the rest 80% is paid by the insurance company.

What Does Out-Of-Pocket Limit Mean?

Out-of-pocket limit is an expense that the insured has to pay annually on their insured healthcare costs. This is the total amount of money spent on different features such as deductibles, copays and coinsurances. The health insurance company pays for the remaining costs after the insured reaches the maximum out-of-pocket limits per year on their health insurance plan.

Key difference between Coinsurance, Copay, and Deductible

Let’s take a look at the differences between these variables – copay, coinsurance, deductible -in the table below:

Copay	Coinsurance	Deductible
Copay is a set amount that is paid by the insured for charges such as prescriptions, doctor visits etc.	Coinsurance is the percentage of cost that is paid by the insured after meeting his/her deductible amount	A deductible is the set sum of money paid by the insured for various healthcare services before the insurer starts paying for the policy
Copay varies depending on the type of treatment or visit	This amount is generally smaller than copay depending on the service/procedure	Insurer starts paying for claims only after deductibles are met
Copays doesn’t count towards deductibles, rather they count towards the maximum out-of-pocket limit per year	Coinsurances only apply to insured services under your health plan. It doesn’t consider services not covered by the plan	Individual deductibles are charged for dependent members under family floater policies, making the amount higher
Mostly paid before meeting deductible	Paid after meeting deductible	Deductibles has to be paid first before the insurer starts paying for the policy

 

Does a Health Insurance Policy with the Provisions of Copays, Deductible and Coinsurance Make Sense?

If you prefer to buy a cost-sharing insurance plan, there are some advantages and limitations available at the same time. For instance, buying a cost-sharing plan may lower your premium amount, but it will make you obliged to share a portion of the healthcare bill upon claim filing. So, it will imply that you would require cash to pay that amount, which might be a cause of concern at times. Hence, it is up to the policyholder to choose an insurance plan with or without cost-sharing options depending on his/her needs and preferences.