Copayments, or copays for short, is a form of cost sharing between you and your insurer for specific medical services. The copay is the amount of money you typically pay a doctor at the time of your visit. For some services, like hospital visits, you will most likely get a copay bill after you’ve been treated.
Your insurance company negotiates prices with a network of doctors, specialists and hospitals for every medical procedure imaginable. As part of that negotiation, a portion of your share of the bills are set, too, as your copayments — fixed amounts you pay out of your pocket for specific services. Copays are typically around $20 to $50.
Basically, copayments, or co-pays, are a pre-set amount that you pay for certain medical services.
Copay amounts remain the same for the entire year, as long as you see doctors and providers in your network.
As long as you stay “in network” with providers who have agreed to prices with your insurer, your copay share should be the same relatively low amount, no matter what those providers might charge another patient with different insurance — or no insurance at all — for the exact same treatment. Providers commonly have many different contracts with insurers with varying prices. But all that matters to you is the fixed-price copay your network provider and insurer have agreed upon for your service for the year. Tip: Call ahead to your provider and ask what the copay amount is for the treatment you have in mind to avoid surprise bills after you’ve been treated.
How Do Copays Work?
Expect various copays during basic doctor visits depending on the range of distinct services you receive. If you hurt your foot and visit your family doctor, you’ll pay a copay for the visit – say $30 – while your plan covers the rest of his normal fee.
If you visit any one of the network specialists, like a podiatrist for your foot, you should expect to pay a higher copay for that specialized treatment — let’s say $50 or more. But once again, your plan will cover the rest of that doctor’s usual fee, which may top $200 or $300 for one visit. With most plans, the insurer only picks up the remainder of the cost after you have paid enough medical bills to meet your deductible.
The Same Price for Any Doctor: To recap, if you see two network doctors for the same services, you will pay the same copay, though one doctor might normally charge $150 and the other $250. Your insurer covers the balance.
How Much Can You Expect to Spend in Copays?
Most common procedures require a copay, as do standardized tests like x-rays. Prescription drugs also have copays, whether you pick them up from a pharmacy or receive them directly from your provider or hospital. Drug copays vary widely, brand names are different than generics, and both types are affected by the tier the insurer assigns to a specific drug, meaning your copay may be minimal or merciless.
What Are Common Copays to Expect?
Generally, an in-network insurance copay for a family doctor is between $20 and $50 per visit. Copays for specialists can be anywhere from $50 to $100 or more.
What Is the Average Copay?
The average cost of copays is $25 for primary care and $40 for specialists, Some recent studies show the median annual copay nationwide ranged from about $360 to $1,500, depending on the state and the amount of medical care needed. Overall, the cost of copays did not increase from 2018 to 2019, the latest years available, and as a rule, tend to increase slower than other healthcare costs. In some plans, copays actually decreased over the years as deductibles skyrocketed.
Where Can You Find Copay Amounts?
You don’t need to memorize your copayment amounts. But you do need to know where to check them to be prepared for basic healthcare costs. You can check for copayment amounts in two places:
1. Your insurance card
Many insurance cards will list basic copay information: the amount for an office visit to a primary care physician, a specialist and possibly, a hospital visit. But not all cards have this information. Any dollar amounts printed on your card likely refer to your copay.
2. Your Summary of Benefits and Coverage
Your Summary of Benefits and Coverage (SBC) explains your health plan in detail. This is where you should look for copay or coinsurance amounts for very specific services you may be considering.
You should receive an SBC in the mail or an email with a link directly to your plan when you enroll and each year before you renew, so you can weigh any significant changes in your coverage. You also can review your plan details on your insurer’s website at any time, or phone the company to get a list of its copays and other details. .
How Do Copays Work With Other Out-of-Pocket Costs?
Copayments are just one part of your insurance coverage. They join other key features — deductibles and coinsurance – to make up your total costs for medical care.
Can Copayments Go Towards Your Deductible?
Before you sign up for a policy, you need to understand all the plan’s costs, including your deductible. That’s the term for the amount you pay for medical treatment before your insurer contributes a dime.
Pay attention to whether your copayments count toward your deductible, thereby helping you to reach the amount you need to spend on your own before your insurer begins paying. Most payments, including copayments, are deductible because they help you reach your plan’s annual deductible. As you probably noticed, your copays have remained relatively similar from year to year. That’s because insurance companies have been hiking deductibles significantly so they can afford to keep copays stable.
“Copay after deductible” means that, unfortunately, you have to pay for a service in full until you reach that annual deductible.
However, many health plans help pay for certain services before you reach your deductible. Preventive care and specialist visits for chronic conditions often do not count towards your deductible. But if these visits include a copay, then that copay will still help chip away at your deductible.
What’s the Difference Between Copays and Coinsurance?
Co-payments are a flat fee for medical services. Co-insurance is a fixed percentage you pay for a specific service, often an expensive service, unfortunately.
It’s no wonder that most people have difficulty telling the difference between co-payments and co-insurance. Their names are confusingly similar, and they also come into play for the same services.
On many occasions, you’ll pay copays and coinsurance for a particular procedure, test or service. Most times, you’ll be asked for your copay when you first arrive at a doctor’s office, laboratory or radiology location. Days or weeks later, you may receive a bill for the co-insurance amount, which is the percentage of the cost that you are responsible for paying.
What’s the Difference Between Copays and Premiums
Your premium is your monthly charge to keep your health insurance plan active. It is the same amount each month, regardless of the amount of care you receive.
By contrast, you are charged copayments each time you get certain services, like going to the doctor’s office, or having x-rays or bloodwork taken. Depending on your health, you may have copayments several times in one month, or none for an entire year.
Do You Pay Copays After You Reach an Out-of-Pocket Maximum?
Your health plan will pay 100% of your medical bills after your combined out-of-pocket spending for doctors, drugs, and other services reaches the plan’s maximum out-of-pocket level (MOOP). In most cases, this amount does not include what you pay in premiums each month.
Once you reach your maximum out-of-pocket cap — except for your premiums — you won’t pay another dollar for treatment, including for deductibles, coinsurance, and copayments.
Can You Use a Health Savings Account (HSA) for Copays?
Your copayments can be paid from your Health Savings Account (HSA). They are considered eligible medical expenses.
Does Medicare Have Copays?
Do Government Programs Have Copays?
Rules for Medicaid depend on your individual state. Medicaid is provided through state government, so the rules are different for each state. Most states do not require copays but some do require a small payment.
What Are Drug Copays?
Prescription drugs also require a copayment. Sometimes it may be as little as a few cents – when you have a very good health plan – but it can be as high as hundreds of dollars for certain drugs.
Health policy researchers found that first tier drugs (generic drugs in a health plan) had an average copayment of $11. Fourth tier drugs (the most expensive level) came with an average copayment of $111.