Most health insurance plans are written with the expectation that plan members will share in the cost of healthcare. A copay is just one of these ways.  

A copay is a fixed amount that a patient is required to pay for certain healthcare services, usually office visits. The co-pay is collected from the patient upfront and it cannot be billed to the health plan for reimbursement.

Copays can be tied to:

  • Surgery
  • Emergency room visits
  • Urgent care visits
  • Therapy visits
  • DME
  • Allergy tests
  • X-rays
  • Lab work
  • Scans
  • Inpatient care
  • Prescriptions
  • Office visit
  • Mental health services
  • Injections

The average copay is about $5.00 - $25.00 per office visit and $100.00- $500.00 for other services like surgery and hospital admissions. The patient is required to pay the co-pay amount for each encounter.

Think of a copay kind like a service fee, lets say your dishwasher breaks down and the service technical charges you $60.00 just to come to your house and check it out. You may be charged additional fees if you decide to have it repaired.  The copay will be   charged on top of any other medical services that may be performed. 

                                                               In a nutshell

A copay is a relatively small, upfront costs that are a requirement of some of the managed care plans, primarily HMO plans and it is usually much cheaper than a plan deductible. The average plan deductible usually starts at around $100.00 and can reach several thousands of dollars.

For patients that only see a medical provider once or twice per year, and can afford it, a small copay is an excellent way to minimize their out of pocket costs while still giving them access to the care they need.

But for patients that visit a doctor frequently, say several visits per year, a $20.00 per visit copay, payable each visit, may pose a hardship. A patient may end up paying the equivalent of a low end deductible by the end of the year.

Perhaps another purpose to copays may be to try to make plan members mindful of the staggering cost of healthcare so they can try to control costs. 

The thought is that “if you have to pay for it, you will make sure you really need it.”

For example, you may choose the lowest, least expensive level of care, you may opt to start with over-the-counter drugs as a way to treat minor ailments or injuries, you may schedule a visit with a medical provider and not use the emergency room to treat a cold or a small laceration and you may choose to limit the amount of doctors you see for a particular ailment.

Of course, the flip side to this is that co-pays can be a deterrent for those who just cannot afford them. Imagine a family of five needing to see a doctor but having to come up with a $20.00 copay, per person, per visit. This may mean that critical care could be delayed and a minor condition could end up costing way more than it should have because care was not sought early. 

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