What Is A Copay?
A copay is a flat fee you’re required to pay at the time of receiving medical service or care.
The amount of your copay depends on if it’s a visit for a doctor, specialist, or even emergency care. Copays for doctor visits are generally lower compared to specialist or urgent care visits.
A copay, or copayment, is a fixed dollar amount you pay every time you go to the doctor or fill a prescription. It’s a shared cost between you and your insurance company. You pay the copayment, and your insurer pays the rest of the bill typically.
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Your insurance company sets a fixed copay amount for the respective service. After you reach your annual out-of-pocket maximum, you will no longer have to pay copays.
Here’s an example on how copays works:
- Total cost: $100
- Insurance pays: $80
- Your copay: $20
The rate usually stays the same regardless of how many times you see your doctor. However, the cost can vary based on different services, such as lab tests, seeing specialists, or urgent care visits. The copay amount can also change based on the brand name or generic medications.
While health insurance plans vary depending on the coverage level, policies with higher monthly premiums generally have lower copays. Plans with lower premiums tend to have higher copays. If you frequently go to the doctor’s office, consider selecting a plan with a lower copay for visits.
Copays and coinsurance are two different costs shared with your insurance company. Coinsurance is a percentage of a total medical bill split between you and your insurer. For example, your insurance plan may cover 80% of the cost, while you’re responsible for the remaining 20%. Coinsurance usually begins after you have met your deductible, whereas copays generally must be paid at the time you receive care.
Here’s an example of how they work with your plan:
A copay is a flat rate you will pay for a visit to the doctor. For example, a primary care visit may cost $180, but you only pay your copay amount for the visit. That means if your copay for a primary care visit is $20, you pay $20 instead of the $180.
Coinsurance is a cost percentage split between you and your insurance company after you meet your deductible. For example, if your deductible is $1,000, you pay 100% of costs until you reach $1,000. After you reach $1,000, you may only be responsible for 20% of your cost if your plan has an 80/20 coinsurance. This means, after your deductible, you pay 20% and insurance pays 80%.
Let’s see how it works together. If you have a $20 copay and 80/20 coinsurance, for a doctor visit that costs $180:
- Your copay would be $20
- Your coinsurance would be $180 before your deductible is met, and $36 after your deductible is met.
Are you eligible for cost-saving Medicare subsidies?
Your copay is determined based on your level of health insurance coverage. Marketplace policies fall into different categories (gold, silver, bronze, and platinum), also called metal tiers. The types do not represent the quality of care, just the level of coverage. [i]
- Monthly premium: Highest
- Copays: Lowest
- Monthly premium: Higher
- Copays: Lower
- Monthly premium: Moderate
- Copays: Moderate
- Monthly premium: Lower
- Copays: Higher
Your copay amount is usually found on your insurance card.
It depends. Some health plans allow copays to go towards a deductible and others do not. A deductible is an amount you pay out-of-pocket before your health insurance starts to pay for medical services.