What is a copay?
Learn what a copay is and when you’ll need to pay it.
When you purchase an insurance policy, there are some industry terms you’ll want to understand. It’s important to learn the definition of a copay before you receive medical services so you can be better prepared for any costs you have to pay.
Copay Definition
A copayment, also called a copay, is a fixed amount you must pay the doctor for services. Most plans have lower copays for primary care providers and higher copays for secondary care providers (specialists).
How Much Does a Copay Cost?
The copay amount depends on your plan and coverage as well as the type of treatment you are receiving. For example, a copay for a trip to the emergency department will almost always be higher than a copay for a routine doctor’s visit.
When you review your plan information, you should see a breakdown of your required copays for various types of treatments and services. Many insurance companies have separate copay amounts for primary care visits, specialist visits, urgent care visits, emergency department visits, and prescriptions.
Prescription drug coverage may be further split into tiers with different copay amounts for various types of medications. Your health insurance plan may also differentiate between copay amounts for in-network and out-of-network healthcare providers.
When Do I Have to Pay a Copay?
Generally, you can expect to pay a copay for any medical services or prescription drugs. There are some common exceptions.
Under the Affordable Care Act (ACA), most plans cover preventive services at 100%, which means you don’t have to pay a copay or coinsurance. However, grandfathered plans still impose cost-sharing on preventive care.
Not all health plans fall under the ACA regulations, so check with your insurance provider to find out whether preventive services are covered at 100% on your plan. You can also review a list of preventive services on healthcare.gov.
Here’s an example of when you’ll need to pay a copay.
Sam has a sore throat and suspects it’s a strep infection. He makes an appointment with his primary care provider. When he checks in, the clerk checks his health insurance policy and determines he has a $45 copay.
Because Sam had surgery earlier that year, he met the deductible of his high deductible health plan and only owes a copay at office visits now.
Depending on what the medical provider orders, he may owe a coinsurance on procedures or tests.
What’s the Difference Between a Copay and Coinsurance?
A copay is different than any required coinsurance, which is a percentage of the charges you must pay from a provider or facility for covered services. Coinsurance is usually presented as a percentage of medical care.
For example, a health insurance plan might have a $1,000 deductible, followed by 80/20 coverage. This means that after you have met your $1,000 deductible (or paid for your first $1,000 of covered expenses out of your own pocket), your insurance will cover 80% of the remaining covered expenses for the plan year and you would cover the other 20%, up to your out-of-pocket maximum.
After you have met your out-of-pocket maximum for the year, you should no longer be required to pay copayments or coinsurance for covered medical treatment with in-network providers.
Questions? Ask the experts.
If you are confused by health insurance and what you’re required to pay when seeking treatment, you’re certainly not alone.
Contact our Member Services team with any questions you have, and a friendly, knowledgeable team member can assist you. You can call 800-538-5038 weekdays from 7 a.m. to 8 p.m. and Saturdays from 9 a.m. to 2 p.m.
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