Copay vs coinsurance: what 2026 plans actually charge
A copay is a set dollar amount, like $40 for a visit. Coinsurance is a share of the bill, like 40%, usually after your deductible. In 4,044 marketplace plans, most use a flat copay for everyday visits. For a hospital stay, 72.40% charge only a share after the deductible.
The short version
A copay is a set price. You know it before you walk in.
Coinsurance is a percentage of the bill. You only know what you owe once the bill is in.
Most plans mix both. They often use copays for small, common care and coinsurance for big, costly care.
What each word means
HealthCare.gov defines a copayment as "a fixed amount ($20, for example) you pay for a covered health care service."
It defines coinsurance as "the percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible."
| Copay | Coinsurance | |
|---|---|---|
| What it is | A set dollar amount | A share of the bill |
| Example | $40 for a visit | 40% of the bill |
| Do you know it up front? | Yes | Only once the bill is in |
| Usual use | Visits and generic drugs | Hospital stays and the ER |
The question that matters more: before or after the deductible?
Your deductible is what you pay before the plan starts sharing costs.
Some copays apply right away. Others only kick in once you have paid your deductible. Until then, you pay the full price.
CMS tells insurers how to label this. In its instructions to insurers, a plain dollar copay means the benefit "is not subject to the deductible." A copay marked "after deductible" means it is.
That label decides whether a $40 visit costs you $40 or the full bill.
What we checked
We used the 2026 federal marketplace plan files for the 30 states that use HealthCare.gov.
We took the standard on-exchange version of each plan, which gave us 4,044 plans. For each plan, we read how it charges for six common services.
We sorted each answer into one of these groups:
- a flat copay that applies before the deductible
- a copay that applies only after the deductible
- coinsurance after the deductible
- full price until the deductible, then free
- free from the start
A small number of plans use mixed or per-day charges. We counted those as "other" rather than force them into a group.
Everyday care: copays win
For common visits and generic drugs, most plans use a flat copay that applies before the deductible.
| Service | Plans | Flat copay, before deductible | Pay toward deductible first | Median flat copay |
|---|---|---|---|---|
| Primary care visit | 4,044 | 3,084 (76.26%) | 487 (12.04%) | $40 |
| Specialist visit | 4,044 | 3,207 (79.30%) | 818 (20.23%) | $80 |
| Urgent care | 4,044 | 3,257 (80.54%) | 702 (17.36%) | $60 |
| Generic drugs | 4,044 | 3,228 (79.82%) | 523 (12.93%) | $15 |
"Pay toward deductible first" covers all three deductible-first groups. You pay the full price for that care until your deductible is met.
Hospital care: coinsurance wins
For the big bills, the pattern flips.
| Service | Plans | Coinsurance only, after deductible | Share |
|---|---|---|---|
| Emergency room | 4,044 | 2,730 | 67.51% |
| Hospital stay | 4,044 | 2,928 | 72.40% |
So for most plans, an ER visit or a hospital stay works like this. You pay the full bill until your deductible is met. Then you pay a share of what is left.
Where coinsurance shows up for visits
Some plans use coinsurance even for visits. Here is the median share when they do.
| Service | Plans using coinsurance after deductible | Median share you pay |
|---|---|---|
| Primary care visit | 138 | 40% |
| Specialist visit | 401 | 50% |
| Urgent care | 302 | 40% |
| Generic drugs | 154 | 20% |
Bronze vs Expanded Bronze: the biggest split
This is the finding that stood out most.
Standard Bronze plans almost never give you a flat copay before the deductible. Expanded Bronze plans usually do.
| Metal level | Primary care, flat copay before deductible | Specialist, flat copay before deductible | Generic drugs, flat copay before deductible |
|---|---|---|---|
| Expanded Bronze (1,156 plans) | 880 (76.12%) | 833 (72.06%) | 961 (83.13%) |
| Bronze (144 plans) | 10 (6.94%) | 1 (0.69%) | 14 (9.72%) |
| Silver (1,453 plans) | 1,158 (79.70%) | 1,252 (86.17%) | 1,226 (84.38%) |
| Gold (1,172 plans) | 999 (85.24%) | 1,079 (92.06%) | 984 (83.96%) |
| Platinum (44 plans) | 32 (72.73%) | 41 (93.18%) | 43 (97.73%) |
| Catastrophic (75 plans) | 5 (6.67%) | 1 (1.33%) | 0 (0%) |
Only 1 of 144 standard Bronze plans has a flat specialist copay before the deductible. Among Expanded Bronze plans, 833 of 1,156 do.
Why Expanded Bronze is different
Federal rules allow a wider value range for some bronze plans.
Under 45 CFR 156.140, one way a bronze plan qualifies is if it "covers and pays for at least one major service, other than preventive services, before the deductible."
That is the Expanded Bronze design. Paying for a service before the deductible is part of how these plans qualify. Our data shows most of them do it for visits and generic drugs.
Which one is better for you
Neither is better in every case. It depends on how you use care.
| If you... | Look for |
|---|---|
| See doctors often | Flat copays that apply before the deductible |
| Take regular generic drugs | A flat generic copay before the deductible |
| Rarely need care | Lower premium; deductible-first design may be fine |
| Worry about a hospital stay | The out-of-pocket maximum, since coinsurance stops there |
Coinsurance has no fixed dollar limit per visit. The cap that protects you is the plan's out-of-pocket maximum, as HealthCare.gov's coinsurance example shows. Our post on deductible vs out-of-pocket maximum explains how that cap works.
How to read a plan's cost sheet
Look at the words next to each price, not just the number.
- "$40" on its own means you pay $40, even before the deductible.
- "$40 copay after deductible" means you pay full price until the deductible is met.
- "40% coinsurance after deductible" means full price first, then 40% of the bill.
- "No charge after deductible" means full price first, then free.
What this does not tell you
We want to be plain about the limits.
Our data covers the 30 states on HealthCare.gov. States that run their own marketplace are not included.
A percentage is only as useful as the price it is applied to. We do not know what each service costs where you live.
We report each plan's cost sharing as the plan files state it. We did not audit each plan's own documents.
Where these numbers come from
Every figure in this post comes from our own database, queried live on the day of publication.
- Plans: 4,044 plans from the 2026 federal marketplace plan files, standard on-exchange version only, 30 HealthCare.gov states
- Cost sharing: each plan's in-network copay and coinsurance for primary care, specialist, urgent care, generic drugs, emergency room and hospital stay
- Labels: read using CMS's definitions in its instructions to insurers
- Medians: taken only across plans in that group, such as plans with a flat copay
Questions people ask
What is the difference between a copay and coinsurance?
A copay is a set dollar amount, like $40 for a visit. Coinsurance is a share of the bill, like 40%. You know a copay up front; you only know coinsurance once the bill is in.
Do copays count before the deductible?
It depends on the plan. In our data, 3,207 of 4,044 plans charge a flat specialist copay before the deductible. Others make you pay full price until the deductible is met.
Which plans use coinsurance for a hospital stay?
Most of them. In our data, 2,928 of 4,044 plans charge only coinsurance after the deductible for a hospital stay. That is 72.40%.
What is a typical copay for a doctor visit?
Among plans with a flat copay before the deductible, the median is $40 for primary care and $80 for a specialist.
Is coinsurance or a copay better?
A copay is easier to plan for. Coinsurance can cost more on a large bill, but the out-of-pocket maximum caps what you pay in a year.
Do Bronze plans have copays?
Standard Bronze plans rarely do before the deductible. Only 1 of 144 has a flat specialist copay before the deductible. Expanded Bronze plans usually do: 833 of 1,156 have one.
What does "copay after deductible" mean?
You pay the full price for that service until your deductible is met. After that, you pay only the copay.
Where do I find this for a plan I am looking at?
Check the plan's summary of benefits. Look for the words "after deductible" next to each price.