What is a Copay?

Tricia Christensen
Tricia Christensen

Even if you have medical insurance, it doesn’t necessarily mean that you get to visit a doctor, lab, or hospital, or purchase your prescription drugs for free. Instead most insurance companies require the insured to pay a portion of their total bill, at a set amount. In other types of insurance, like auto insurance, you have what is called a deductible, a set amount the insured person pays before the insurance company begins reimbursing the insured or others for damage of property or injury. Health insurance may employ either a copay or a deductible, or both.

Health insurance may employ either a copay or a deductible, or both.
Health insurance may employ either a copay or a deductible, or both.

In the past, before the advent of insurance care with network doctors and facilities, and primary care physicians, many health insurance companies operated on the 80/20 principle. When you went to a doctor’s office, you paid 20% of the bill, and either you or the doctor’s office billed the insurance company for the rest. This principle may still operate with certain types of insurance. For instance, people who have the ability to choose doctors out of network may pay 20%, or another percentage of the total instead of paying the flat fee they would for visits to network doctors. A network doctor is contracted with the insurance company to accept a set fee for services.

Many health insurance policies require a copay for emergency room visits.
Many health insurance policies require a copay for emergency room visits.

Since the 1970s, the shift in insurance trends has been for most people to be enrolled in a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), making the term copay very familiar. While some services may be offered without a copay or copayment, other services mean you will always have a set copay. For instance you might pay $15-25 US Dollars (USD) for a standard visit to a network or preferred provider doctor.

A copay is typically paid at the time that medical services are rendered.
A copay is typically paid at the time that medical services are rendered.

The statement that the copay is set at a certain amount needs to be further explored. Each service may have a different copayment, and some may not be covered at all. You might pay $100 USD for visiting an Emergency Room, $25 USD for a doctor’s visit, and $15 USD for prescriptions.

Copays may be cheaper for individuals enrolled in a Health Maintenance Organization.
Copays may be cheaper for individuals enrolled in a Health Maintenance Organization.

You may pay a higher copayment at the pharmacy if you specifically choose a name brand medication instead of a generic medication. Prices may change each year, as companies renegotiate with insurance companies. In early years when the copay was first introduced, amounts for a doctor’s visit were usually between $5-15 USD. Typically copayments are higher now, in the nature of $20-30 USD for a doctor’s visit. The trend in the insurance industry is to raise copayments without raising compensation for doctors; in other words, you pay more and the insurance company pays less to compensate medical professionals.

Visiting a specialist may result in a higher copayment for the patient.
Visiting a specialist may result in a higher copayment for the patient.

Deductibles need to be understood too, since it may be necessary for you to fulfill your deductible amount prior to beginning to make copayments for services. For instance you might have a $500 USD deductible on your plan. If you were hospitalized, you may have to pay that amount, rather than simply your copayment. If you have additional doctor’s visits or hospitalizations, once you’ve met your deductible, you will only pay the designated copay amount. Some services are exempt from meeting your deductible, like well-child visits and yearly gynecological exams. Other insurance companies offer a low deductible that is easily met with a few copays to a doctor.

Under some health insurance plans, patients are always required to pay a set copayment.
Under some health insurance plans, patients are always required to pay a set copayment.
A person may pay a higher copayment at the pharmacy if a name brand medication is used instead of a generic medication.
A person may pay a higher copayment at the pharmacy if a name brand medication is used instead of a generic medication.
Tricia Christensen
Tricia Christensen

Tricia has a Literature degree from Sonoma State University and has been a frequent wiseGEEK contributor for many years. She is especially passionate about reading and writing, although her other interests include medicine, art, film, history, politics, ethics, and religion. Tricia lives in Northern California and is currently working on her first novel.

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Discussion Comments

anon993786

If the patient is experiencing hard times, can the doctor opt to not charge the co-pay, or even share part of the insurance payment with the patient?

spawn123

Why did I get charged a copay three times for the same injury? First by my doctor who then sent me to a specialist then the specialist sent me for an mri and then I went back and had a follow up on the mri. I got charged by my doctor then twice by the orthopedist once at the first visit, then again three days later at the follow up.

anon78351

@anon18643: No, they are not.

Please read the article before commenting.

It says:

"Instead most insurance companies require the insured to pay a portion of their total bill, at a set amount. other types of insurance, like auto insurance, you have what is called a deductible, a set amount the insured person pays before the insurance company begins reimbursing the insured or others for damage of property or injury. Health insurance may employ either a copay or a deductible, or both."

anon64788

Can an MD charge a copay for post op?

anon18643

Are copay and deductible the same?

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