Copay, deductible, coinsurance: what is the difference?

These are the three flavors of the patient’s share. They are easy to mix up and they behave very differently.

Copay. A small fixed amount the patient pays at each visit, like fifteen dollars. It does not depend on what the visit cost. It is usually collected at the front desk, before the claim even exists.

Deductible. The amount the patient must pay out of their own pocket each year before insurance starts paying. Some things are covered before then, like a copay visit or preventive care. If the deductible is not met, the payer can allow the charge, write off its contractual part, and still pay you nothing, because the whole allowed amount belongs to the patient. That is the single most common reason a patient owes the entire bill. See Why does the patient owe the whole bill?.

Coinsurance. A percentage. After the deductible is met, the patient might still pay twenty percent of each bill and insurance pays the rest.

On a payer’s answer sheet these arrive as codes starting with PR, which stands for patient responsibility. PR-1 is the deductible, PR-2 is coinsurance, PR-3 is the copay. A PR code means that money belongs to the patient, so the next step is usually a statement.