What is a Copay?

Continuing the round of "definitional" posts to get this blog started ... it's time to talk copays.

Copays are fees that you are required to pay each time you have a particular service under your health insurance. These fees take the form of a flat dollar amount that you pay each time you have a particular service - for example, $15 per office visit or $50 per emergency room visit.


When shopping for insurance policies, most companies will tell you what the office visit copay will be on your plan. However, you should also understand that many policies will have copays for a range of other services - for radiology services (x-rays, MRIs, etc), for laboratory services (blood tests), for surgeries, for emergency room visits (which are usually waived if you wind up being admitted to the hospital), or for durable medical equipment (crutches, a knee brace) your doctor might give you in his or her office ... as well as separate copays on prescription drugs.

And also, you should understand that the copays for those other services are not necessarily the same dollar amount as the office visit copay they quote you. You want to make sure to read your plan documents carefully before you sign up, so that you aren't saddling yourself with a plan that has a $10 office copay, but a $100 copay on everything else you might use it for.

The size of copays vary widely by plan - I've seen office visit copays ranging from $5 per visit to $75 per visit and ER copays ranging from $50 to $500. My general recommendation, if you're picking a plan, is to pick a plan that has an office visit copay that is an amount you wouldn't have trouble paying up front if you suddenly got sick and found yourself having to go to a doctor. Doctor's offices will typically ask you for your office visit copay up front when you are treated, so you'd hate to be scrambling to find the money to pay a particularly high copay ... and that goes double if you are prone to sickness or if you have to see a doctor regularly for a chronic health condition.

You will not have to start paying your copays until after you have met your annual deductible, although your doctor's office will likely ask you to pay it even if you haven't met your deductible yet that year. It's perfectly okay to pay your copay up front - copays don't "run out" like your deductible does, so it would be unusual for you to overpay if you paid up front.

However, since plans often do have different copays for a range of services, you shouldn't be surprised if you ultimately get a bill after you leave the office, even if you've met your deductible. For example, if you have a plan that charges $20 copays for each of the above categories of services, and then you visit the doctor for a knee injury? Don't be surprised if you wind up getting a bill for $40 after you paid $20 in the office - your insurance will charge you $20 for the office visit copay, $20 for an xray, and another $20 for the knee brace you left with.

Copays are the most straightforward and predictable category of ways that you can be billed through your insurance, and problems involving copays are pretty rare. For those reasons, they are a good, predictable category of out-of-pocket costs to have on a plan. On the other hand, they can add up quickly if you have high copay dollar amounts and if you see the doctor pretty regularly. So be sure to read your insurance plan documents carefully and to think closely about how much you can afford up front before you sign on the dotted line.

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I'll post a few more "definitional" posts in the upcoming month or so, and then I'll move onto advice about how to deal with specific problems that may arise or questions you may have while dealing with your health insurance. In the meantime, please feel free to leave a comment or email me at medbillhelp at gmail dot com if you have any general questions or ideas for future posts. Thanks for reading!