Copays Explained

If you currently have health insurance, take a look at your insurance card — the copay amount is often displayed. If you’re shopping for insurance, take a look at the plan tiles, and you’ll see that copays are featured pretty prominently.

These dollar amounts will become very familiar throughout the year, because every time you see your healthcare provider or specialist, these copays are what you’ll be expected to pay — usually right there on the spot.

The good news is that in many cases, the copay is the only amount you’ll pay for the medical care you need.

Some things to keep in mind

Always double-check when you’re asked for a copay. Under the new healthcare law, certain preventive services are 100 percent covered, so you shouldn’t have a copay for those. However, some providers are not up to speed on the new rules and are mistakenly asking for copays for every visit. As a savvy consumer, you’ll know which services are considered preventive and don’t require a copay, as long as you’re seeing a provider in your network.

You might be able to get help paying your copays. If you qualify, the federal government might cover some or all of your copay cost — through what’s called cost-sharing reductions. To take advantage of your cost-sharing reduction, you’d have to buy a silver tier plan. Be sure to check your eligibility for cost-sharing reductions before you shop for insurance.

(Also: Check to see if you qualify for Medicaid or CHIP for your kids, other ways to get insurance that’s affordable or even free, with small or no copays on anything.)

Some plans use deductibles and coinsurance in place of copays (sadly, this doesn’t mean that all your visits are free). If you see a plan with a percentage (rather than a dollar amount) for office visits and prescription drugs, it means your insurance carrier probably won’t start helping you pay for your medical care until you’ve hit your deductible — unless it’s preventive care. The benefit of this type of plan is that it’s likely to have a much lower monthly premium. If you don’t have a pre-existing medical condition and you don’t anticipate using much medical care during the year, this type of plan might be worth considering.

Copays usually apply only to in-network healthcare providers. If you’ve got a plan with copays, it means your insurance carrier has made an agreement with all the healthcare providers in your network and they’ve worked out how much everything costs and how much everyone pays. As long as you stay in-network, your copay will be what you expect. If you go outside your network, you won’t know how much it will cost (but it’ll most likely cost more).

A copay doesn’t cover tests or supplies. Let’s say you cut your finger while chopping veggies so you go to an urgent care clinic. You see a nurse practitioner who gives you a few stitches and sends you on your way. In this case, your copay will cover the nurse’s time. But your copay may not cover the thread used for the stitches, so you could get a bill for that later.

Some other examples of services that you may be charged for in addition to the copay: a throat swab (for strep) if you see your doctor for a sore throat; blood work; an ultrasound or X-ray to check for a broken bone — you get the idea.

Different services have different copay amounts. Depending on the plan you choose, you’ll probably have one copay for office visits, another for emergency room visits, yet another for urgent care clinics, and maybe a different copay when you see a specialist. You might also have different copay amounts for brand-name prescriptions vs. generics, or for different tiers of medications. When you’re comparing plans, be sure to look at all the different copays and consider which types of services you’re most likely to use through the year. (For help comparing plans, use the GetInsured Plan Scores or talk to one of our licensed brokers.)

Copays are generally due at the time of service. So be sure to bring cash, your checkbook, or a credit card when you visit the doctor.