What Is A Copay?

If you have health insurance, you must have come across the term copay or co-payment. However, if you are still unsure as to what it is, then you have come to the right place. Continue reading this article to find out more details.

What is a copay? A co-payment or copay is a fixed sum for a covered service, paid by a patient to the supplier of a service prior to getting the service. It very well might be characterized in an insurance policy and paid by an insured individual each time a medical benefit is gotten. It is actually a type of coinsurance, yet is characterized differently in medical coverage where a coinsurance is a rate payment after the deductible up to a specific limit. Besides, it should be paid before any policy benefit is payable by an insurance company. Co-payments do not ordinarily contribute towards any policy cash based maxima, while coinsurance payments do.

Insurance companies utilize co-payments to share medical services costs to forestall moral peril. It could be a little part of the actual cost of the clinical benefit, yet is intended to stop individuals from looking for clinical care that may not be fundamental (e.g., an infection by the common cold). In health systems with costs beneath the market clearing level in which holding up records go about as proportioning apparatuses, co-payment can serve to decrease the welfare cost of waiting lists.

Cost Sharing

It is imperative to comprehend the cost-sharing subtleties of any health care coverage plan you are considering, particularly for services or prescriptions that are often used. Remember that these are cash based costs you will pay along with monthly premiums, and costs for non-covered services. So, when it comes to cost-sharing, is a copay all you pay? Cost sharing usually comes in three forms:

  • Co-payment: This is a fixed, level charge for particular sorts of office visits, prescription drugs, or different services. Since the health insurance copay is fixed, you will know early the precise amount you owe. On the off chance that your policy records a co-payment of $25 for a specialist visit, you pay that sum each time you see the specialist.
  • Coinsurance: This is a percentage of the total expense for a covered clinical benefit, rather than a fixed co-payment. In the event that the insurance company owes a doctor $100 for your visit, and you have a coinsurance of 25%, you will pay $25 for the visit. You may pay it at the hour of service or get a bill for your bit after the visit.
  • Annual deductible: A yearly deductible is a set sum that you might be needed to pay toward covered clinical care in a matter of a year. For instance, on the off chance that you have a $3,000 yearly deductible, you may have to pay that sum cash based toward covered clinical care before the insurance company will start paying your claims.

Do you pay copay after out-of-pocket maximum is met? For the most part, you will pay completely cash based for covered clinical benefits until you arrive at your policy’s yearly deductible. From that point forward, your insurance begins to pay for a lot of costs, and you may owe a co-payment or coinsurance for specific services as your “share.”

Co-pays are a type of cost sharing. Insurance companies use them as a means for clients to divide the cost of paying for health care. Co-pays for a specific insurance plan are set by the insurance provider. Notwithstanding what your doctor charges for a little while, your copay will not change.

It is likewise essential to take note of that specific preventive clinical benefits might not have cost sharing. For instance, yearly preventive care checkups, certain screenings, and childhood vaccines are by and large not subject to co-pay, coinsurance, or deductibles. This implies they are usually covered without cash based costs.

What is a copay?

A copay is a fixed cash based sum paid by an inured for covered services. It is a standard portion of numerous health insurance plans. Insurance suppliers regularly charge co-pays for services, for example, doctor visits or prescription drugs. Co-pays are a predefined dollar sum as opposed to a percentage of the bill, and they are generally paid at the hour of service. Not all clinical benefits ask you for a copay. Some insurance companies do not need a copay for yearly physicals. For instance, on the off chance that you hurt your back and go see your doctor, or you need a refill of your kid’s asthma medication, the sum you pay for that visit or medication is your copay. Your copay sum is printed directly on your health plan ID card. Co-pays cover your part of the cost of a doctor’s visit or prescription.

Your copay (or co-payment) tends to vary based on the service you are getting, and your health insurance plan. Nevertheless, they are typically $30 or less. Do I have to pay a copay for every doctor visit? Not all services require a copay — preventive care generally does not — while the copay for other clinical benefits may rely upon which doctor you see or which medication you use. Specifically, certain insurance plans charge more to visit a specialist rather than your primary care physician. Name brand prescription medication generally has a higher copay than nonexclusive variants. When in doubt, health insurance plans with lower month-to-month premiums (the sum you pay every month to have health insurance) will have higher co-pays. Plans with higher premiums typically have lower co-pays.

Co-payments generally do not count toward your deductible, which is the sum you owe for covered health expenses every year prior to when your insurance carrier starts paying a larger sum of your hospital expenses. In any case, the standard meaning of a co-payment can vary between employer-sponsored health insurance and Marketplace plans under the Affordable Care Act (also known as Obamacare). According to Healthcare.gov, a co-payment for these plans is a fixed sum you pay for covered health care services after you have paid your deductible.

For instance, suppose you visit the doctor and have not yet paid your deductible at this point. The admissible cost or maximum sum your insurer will pay for a particular covered health care service is $100. Your co-payment for this current doctor’s visit is $20. But since you have not met your deductible, you owe $100 or the full applicable sum. Nonetheless, on the off chance that you have taken care of your deductible, you will pay $20. The insurance company will pay the rest.

Most plans will cover the total cost for preventive care services, for example, depression and blood pressure screenings when these services are given by a doctor or other supplier in your policy’s organization. However, paying little heed to what sort of plan you have, it is critical to carefully read the summary to your policy to understand what co-payments truly mean, especially under your plan, and the amount you will be charged for what services under what conditions.

How does a copay work?

Your arrangement figures out what your copay is for various kinds of services, and when you have one. You may have a copay before you have completed the process of paying toward your deductible. You may likewise have a copay after you pay your deductible, and when you owe coinsurance. Your Blue Cross ID card may list co-pays for certain visits. You can likewise sign in to your account, or register for one, or use the mobile application to see your plan’s co-pays.

Copay expenses differ among insurance providers,  however, they are regularly $25 to $30 or less. For instance, an insurance plan with co-pays may require the insured to pay $25 per doctor visit or $10 per medicine. Make sure to go through the terms and conditions of your insurance plan to decide your co-payment choice.

On the off chance that the copay option is present, it might incorporate various charges for doctor visits, emergency room visits, specialists’ visits, and other clinical benefits. Insurance suppliers regularly charge higher co-pays for appointments with out-of-network suppliers. It is critical to know about the amount that out-of-network suppliers charge for co-pays, particularly on the off chance that you are making repeating visits. Copay sums may change yearly, so it merits checking in with your insurance company or HR department to see whether the sums have gone up when another year starts.

What is a copay in health insurance?

Copay in Health Insurance alludes to the percentage of the claim sum that must be borne by the policyholder under a health insurance policy. Not many insurance approaches come with a required condition for co-payment, while others offer policyholders the option for  voluntary co-payment, which permits them to lower their premium payment. How can it function? As a rule, with health insurance approaches, you can select two kinds of claims:

  • Cashless treatment choice.
  • Repayment/reimbursement for the costs incurred.

With cashless treatment, your insurance supplier offers to settle your costs caused directly with the hospital where you or any of your family member is going through treatment. Then again, with a repayment claim, the insurance supplier will repay you for the costs brought about while you were going through treatment. Presently, there are two circumstances that can emerge from co-payment:

  • At the point when you choose a higher copay, it will assist with bringing down your absolute premium payment, yet you will have to pay a larger sum during a claim.
  • In the event that you settle on a lower copay, it will lower the sum that you will have to pay during the claim, however you will have to pay a higher premium against your insurance policy.

For example, in the event that you have selected 15% copay, your insurance supplier will bear 85% of the claim amount, while the rest should be borne by you.

Plan that need a health insurance co-pay

Managed care plans, for example HMOs, are where co-payments are more common. The insurance organizations that offer these plans, are also under contracts with health-care suppliers. These health care suppliers let them pay a fixed sum for essential services. Therefore, it becomes a lot simpler to foresee overall costs and to offer a cost sharing structure to clients. However, you can also find other plans, for example PPOs, that include co-payments into their cost-sharing structure, along with yearly deductibles or coinsurance.

Any plan that comes with cost sharing, has benefits for both, the insurance company and its members. This allows insurance companies keep their costs low, and assists the insured individual in knowing what they will owe for each service. Co-payment, coinsurance, and deductible costs can change widely between health plans. Cost sharing can also differ for the same service or prescriptions. In other words, it will be beneficial for you if you shop around and compare cost sharing details for plans you are considering to get.

Services that have a health insurance co-payment

Health insurance co-payment guidelines often tend to vary contingent upon the policy and provider. Make sure that you check the details of your plan’s policy for more information. You may owe a co-payment for:

  • Ambulance or ER services
  • Mental health in-office services such as physiotherapy or drug counseling
  • Occupational therapy
  • Office visits with a primary care physician for non-preventive care
  • Office visits with a specialist
  • Physical therapy
  • Prescriptions
  • Speech therapy

As referenced above, preventive care is for the most part excluded from cost-sharing because of the Affordable Care Act, so co-pays would commonly not matter for these office visits. Remember that your arrangement may have supplier network rules. Your costs might be higher on the off chance that you decide to go out of network, or use a non-preferred doctor or provider. On the off chance that you do go out of network, your co-payment or coinsurance costs might be more, or you might be needed to pay the complete sum for the services.

Types of health insurance copay

Now that you have some idea as to what a copay is when it comes to health insurance, let us take a look at its types. It is not necessary that every health insurance policy will come with mandatory copay clauses. However, if your health insurance policy has this clause, it can be applied in the following ways:

  • On Medical Bills: Under this type, the copay clause is relevant to each one of the claims raised, regardless of whether it is intentional or required. You will accordingly have to pay a bit of the claim sum that is raised in this way.
  • On Senior Citizen Policies: These are the arrangements that for the most part come with compulsory copay clauses. This is generally in light of the fact that the treatment costs for senior citizens are typically a lot higher.
  • For Reimbursement claims & Treatment at any non-network Hospital: Now and then, insurance suppliers only levy the co-payment clause on repayment claims or during treatment at non-network hospitals. Under these conditions, the cashless claims are borne by insurance suppliers.
  • For Hospitalization in Metro Cities: Because the cost of treatment in urban, metropolitan cities is higher than what it is in smaller cities and towns, insurance providers might levy a copay clause for such situations.

Features of health insurance copay

To comprehend what is copay in health insurance, you will also need to know about its features which are as follows:

  • Under this framework, most of your claim is covered by the insurance supplier while you need to deal with a specific level of the cost incurred.
  • The copay rate relies upon the clinical service that you get.
  • In the event that you pick a lower co-payment sum, you would have to pay higher premiums against your health insurance policy.
  • With regard to copay meaning, it can likewise be utilized interchangeably with co-insurance.
  • Copay clauses are for the most part required for senior citizen health insurance arrangements.
  • These are more famous in metropolitan urban areas where the cost of treatment is higher than that of more modest towns and cities.

What else should I know about co-payments?

Now and then, there is a limit on how frequently you can get a specific clinical service at the same co-payment. You may owe a bigger co-payment or the full cost of the service after you have crossed that limit. Preventive care services can likewise have limits. Moreover, co-payments for one service can vary starting from one policy year to the next. Co-payments can likewise differ drastically relying upon whether you got the service in-network or out-of-network.

In the health insurance world, your network is a group of doctors and medical clinics that have consented to acknowledge your plan and have arranged a contract with your insurance provider to minimize expenses. When looking for clinical care outside this organization, you might be answerable for a bigger copay or the complete price tag. The total may likewise shift contingent upon whether you have met your deductible or not.

Give close consideration to the portion of your policy summary that highlights the out-of-network services in the event that you become sick somewhere outside your network and need prompt clinical care. For most plans, nonetheless, what you pay in co-payments will count toward your out-of-pocket maximum for the year. This is the total sum you will pay in deductibles, co-payments, and coinsurance before your insurance provider covers 100% of your remaining hospital expenses for covered services.

As a side note, coinsurance is for the most part the percentage of an in-network covered health care service that you will pay after you have met your deductible. Your insurance provider will cover the rest. For instance, if your policy’s coinsurance is 30%, your insurance provider would cover 70% of the bill after you have paid your deductible. Your charge is the month-to-month sum you owe to your insurance company regardless of whether you got no clinical services that month. It does not count toward your out-of-pocket maximum.

Shopping for health insurance with co-payments in mind

You know yourself better than any other person. This is the reason you might need to focus on plans that offer the most generous co-payments for the services you are well on the way to utilize. Settling on a high deductible and low deductible health plan ought to likewise be affected by how frequently you use which services. As a rule, high deductible health plans (HDHPs) convey lower premiums, co-payments, and coinsurance approaches. Plans with lower deductibles normally come with higher premiums, co-payments, and coinsurance. Contingent upon your arrangement, your co-payments may count toward your deductible. What’s more, is that sometimes, you might have the option to reach at your out-of-pocket maximums through co-pays without even needing to have met your deductible. Generally, the quicker you can get your insurance company to cover the greatest portion of your clinical costs, the better, so consider looking for the policy that will assist you with doing this.

Co-pays vs coinsurance

Co-pays and coinsurance are two different ways that insurance companies share costs with clients, however they contrast in both how and when they can be applied. As mentioned previously, a copay is a set measure of cash that you pay when you get a specific service. The measure of your copay varies, dependent on the service. An office visit to your primary care physician may have a $20 copay, while recording an order for prescription medications may have a $25 copay. Regardless of how much the doctor or supplier charges for the service, your copay is the same.

On the contrary, coinsurance is charged as a percentage rather than a flat fee. For instance, suppose you have coinsurance of 20%. This implies that you need to pay 20% using cash on hand, and afterward your insurance will cover the other 80% of the bill. (This is likewise alluded to as 80/20 coinsurance.) Your coinsurance will also apply along with your copay.

Another significant contrast is that co-pays may apply whether you have met your deductible or not. However, you only pay coinsurance after you have met your deductible or on the off chance that you see an out-of-network supplier. The significant exemption is in the event that you have a zero-deductible arrangement, which will consistently require you to pay coinsurance.

Before you hit your deductible, you should pay cash based when you go to the emergency room or on the off chance that you require dire care, similar to an operation. (On the off chance that you need care to treat a perilous circumstance, your insurance will cover the cost in light of the fundamental health benefits that Obamacare expects insurers to cover.)

Co-pays vs deductible

Apart from visits to the clinic and preventive care, certain medical procedures are dependent upon a deductible. Your health insurance deductible is the measure of your own cash that you need to pay for those procedures before your insurance company will step in to pay for a portion of your clinical costs. A high deductible implies that you pay more yourself before your insurance steps in. What costs count toward meeting your deductible may differ from one plan to another, however co-pays do not typically count toward your deductible.

Co-pays vs out-of-pocket max

Your out-of-pocket maximum, also known as your out-of-pocket limit, is the maximum sum you will have to pay by yourself for clinical costs in the event that you have health insurance. When you hit that spending amount, your insurer will take over to cover the remainder of your costs for the calendar year. Your spending towards the limit will reset once another year begins. Co-pays do count toward your yearly out-of-pocket maximum since they are completely cash based costs. You do not generally need to make co-pays after you hit your maximum, however this changes from plan to plan. Ensure that you check the details of your particular plan for more information.

Co-pays with Medicare and Medicaid

On the off chance that you have Medicare (the government health insurance program for individuals who are more than 65 years old, or have certain disabilities), you can for the most part hope to pay less in co-pays than you would pay for private health insurance or other individual plans from the marketplace. Costs change from plan to plan yet your co-pays, as for a prescription medication, could be under $5. Medicaid plans shift from one state to another, so you should check your individual plan to understand what your co-pays are. Nevertheless, co-pays with Medicaid are for the most part a lot smaller than they are with other plans. For instance, in New York, the copay is $3 for visiting a clinic or getting a brand name subscription.

Is it better to have a copay or not?

Perhaps the greatest benefit with regard to the copay clause is that it assists with bringing down the expense paid towards your insurance policy. Regardless of whether you need to pay a portion of your claim for that, it can be valuable since it lessens your occasional uses by bringing down your premium payment. Nonetheless, insurance approaches which request a high co-payment sum from policyholders can stop the insured individual to look for appropriate healthcare during their period of need, and render the policy futile. Co-payment puts the insured individual in a tough spot since they cannot benefit from the satisfactory healthcare given by insurance suppliers, without paying for a part of the same. Despite the fact that higher copay implies less premium, you will wind up paying more towards your treatment costs than you save on premiums. This is the reason health insurance strategies without copay clauses are considerably more common and popular with the public than those which levy it.


A copay may discourage individuals from looking for vital clinical care and higher co-pays may bring about non-utilization of fundamental clinical benefits and prescriptions, thus rendering somebody who is insured, viably uninsured in light of the fact that they cannot pay higher co-pays. In this manner, there is a balance to be accomplished: a sufficiently high copay to deflect unnecessary costs, however low enough to not make the insurance futile. While picking an arrangement, consider whether you expect to have a lot of hospital expenses. Assuming this is the case, it might bode well to purchase a more costly arrangement with lower co-pays and a lower deductible. Furthermore, watch out for the maximum out-of-pocket limits too.

Charles Bains

Charles Bains

Charles Bains started his insurance career as a marketing intern before pounding the pavement as a commercial lines agent in Orlando, FL. As an industry journalist, his articles have appeared in a variety of trade publications. His insurance television career, short-lived but glorious, once saw him serve as the expert adviser on an insurance-themed infomercial (yes, you read that correctly). Having recently worked for various organizations, coupled with his broader insurance knowledge, Charles is able to understand our client’s needs and guide them accordingly. He is a gem for Insurance Noon as his wide area of expertise and experience have been beneficial in conducting further researches to come up with solutions and writing them in a manner which is easy for everyone including beginners to comprehend.

Leave a Reply