A copay, or copayment, is a set fee you're responsible for paying upfront with most health insurance plans when you seek certain medical services such as an office visit with a doctor (whether your primary care physician or a specialist), an urgent care visit or a prescription drug fulfillment. Your copay will depend on your insurance plan. You pay your copay at the time of service. Preventative care is generally exempt from copays.
Copay
Updated: November 5, 2024
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KEY TAKEAWAYS
- A copayment is a fixed fee that policyholders pay for specific medical services or prescriptions.
- Policyholders must pay their copayment when the service is rendered.
- Copayments are counted towards the insurance plan's yearly out-of-pocket maximum but typically do not contribute to the deductible.
How Do Copays Work?
A copay is a common feature of a health insurance plan. Understanding its key characteristics is vital for managing your insurance coverage costs.
It’s a Fixed Fee Per Service
If your plan has copays, you pay a predetermined, fixed amount when you receive certain medical services. Copays can vary for different types of services. For instance, while you may pay $20 for specialist visits, your urgent care copay might be $50.
You Pay at the Time of Service
Copays are due when the medical service is rendered or a prescription is purchased.
Often Waived for Preventive Care
Under the Affordable Care Act, most insurance plans must waive copays for annual wellness visits or routine physical exams to promote regular health check-ups among policyholders.
Varies by Network Status
Copay amounts differ depending on whether the provider is in-network or out-of-network. For instance, an in-network specialist might have a lower copay than an out-of-network specialist.
Doesn't Contribute to Deductibles
Copays typically do not count toward meeting your annual deductible.
Counts Towards Your Out-of-Pocket Maximum
Copays contribute to the out-of-pocket maximum allowable within the policy. The insurance company pays all covered medical expenses if the insured reaches their out-of-pocket maximum.
Copay vs. Co-insurance
Co-insurance is another common feature of insurance plans whereby insurance companies and policyholders share the cost of health care. Despite the similarities of their names, these features operate differently. Here's a side-by-side comparison.
Element | Copayment | Co-insurance |
|---|---|---|
Definition | A fixed amount the insured pays for a specific service or medication at the time of service. | The insured pays a percentage of the total cost for a service or medication. It is typically billed after services are rendered. |
Payment Structure | Predetermined flat fee (e.g., $20 for a doctor's visit). | Percentage of the total bill (e.g., 20% of the hospital bill). |
Predictability | It is more predictable as the amount is fixed regardless of the total cost. | It is less predictable as the amount varies based on the service's total cost. |
When It’s Paid | It is paid for every applicable service until the annual maximum out-of-pocket is met. | It is paid after the deductible is met and only until the annual maximum out-of-pocket is met |
Copay Example
Let's explore an example of copayments in a sample policy. Sarah has a PPO health insurance plan and has two different copay rates listed on her insurance card:
Office Visit: $55
Urgent Care: $80
Her copays are waived for annual wellness visits and other preventative care.
If she sees her primary care doctor because of a sinus infection, she’ll pay $55 either upon arrival or before she leaves.
If she needs treatment for her sinus infection over the weekend and goes to urgent care, she’ll pay $80.
Sarah is relatively healthy and does not reach her maximum out-of-pocket expenses annually, so she can count on paying her copay at every visit.
Copay Frequently Asked Questions
We've compiled a list of frequently asked questions about copays, providing clear and concise answers to help you better understand this common cost-sharing mechanism.
Do all insurance plans have copays?
No, not all insurance plans have copays. The presence and amount of a copay depend on the specific insurance plan. Some plans might have copays for certain services and not for others, or they may have no copay at all, which will often come at the price of higher premiums.
How does a copay differ from a deductible?
A copay is a set fee for specific medical services or prescriptions paid upfront, regardless of the total cost. On the other hand, a deductible is an amount you must cover before your insurance begins paying for services. It’s possible to pay a copay and later pay the full bill if you haven’t met your deductible yet.
Does a copay count towards the annual deductible?
In most plans, copays do not count toward your annual deductible.
Does a copay count towards the annual out-of-pocket maximum?
In most health insurance plans, copays count towards the annual out-of-pocket maximum. Once you reach this maximum, the insurance typically covers 100% of the allowed amount for covered services for the rest of the year.
Related Content
To further enhance your understanding of health insurance and related financial concepts, we've curated a list of resources available on MoneyGeek. Dive deeper into these topics to make informed financial decisions.
Health Insurance Glossary — This comprehensive glossary provides definitions and explanations for various health insurance terms. It's an invaluable resource for anyone familiarizing themselves with industry-specific jargon and concepts.
How to Get Health Insurance — Explore the different avenues through which Americans can obtain health insurance, whether through an employer, the government, or the Health Insurance Marketplace. This guide offers insights into the Affordable Care Act (ACA) and the various tiers of insurance plans available.
Student Health Insurance — Discover the benefits and considerations of student health plans offered by educational institutions. These plans can be an affordable insurance option for students, but it's essential to understand their coverage scope, especially when away from campus or during breaks.
About Nathan Paulus
Nathan Paulus is the director of content marketing at MoneyGeek. Nathan has been creating content for nearly 10 years and is particularly engaged in personal finance, investing, and property management. He holds a B.A. in English from the University of St. Thomas Houston.
sources
- HealthCare.gov. "Health benefits & coverage." Accessed November 5, 2024.