Copay Deductible

When health insurance deductibles are often measured in thousands of dollars, copayments—the fixed amount (usually in the range of $25 to $75) you owe each time you go to the doctor or fill a prescription—may seem like chump change. But copays really. Co-Pay Relief Program Fund Notices. Would you like to be notified when any new funds open, or when any of our current funds re-open? If so, please sign up using the “Get Notified” link below. As a member of our subscriber community you will receive important news about all of. The copay can vary in price based on the type of healthcare service or facility. For example, the copay cost for a doctor's visit is likely to be less than a trip to the emergency room. Note: In most cases, copay expenses do not go toward your annual deductible, but may be.

Health care terms can be confusing. But when it comes to payment types, it’s helpful to know the meaning of the different terms so you know what form of payment is required. The most common types are copays, deductibles, and coinsurance. All three are different types of cost sharing, which is the portion you pay for a medical service or prescription drug.

What is a copay?

A copay is a fixed amount you pay for a health service, seeing your doctor, or filling a prescription. Copays cover your cost of a doctor’s visit or medication. You may not always have a copay, however. Your plan may have a $0 copay for seeing your doctor, for example, in which case you would not have to pay a copay each time you visit your doctor.

What is a deductible?

A deductible is the amount you pay for a service before the plan shares the cost of the service with you. There could be a deductible on medical services or on prescription drug services, but not all plans have a deductible. For example, if your plan had a $200 prescription drug deductible, you would pay the first $200 of your prescription drug costs before your plan helps to pay. If your plan had a $0 prescription drug deductible, your plan would help pay for your prescription drug costs without you having to pay a certain amount first.

What is coinsurance?

Coinsurance is when you pay a percentage of the cost for an item or service. For example, if a medical service has a 20 percent coinsurance, you would pay 20 percent of the cost and your plan would pay the other 80 percent. Coinsurance is when you and your plan both share a percentage of the cost of a service that adds up to 100 percent.

For more information on common health care terms, use this helpful glossary.

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Referrals Are Central to Your Care

Referrals are an important part of an HMO plan because they help your doctor keep track of the care you receive and ensure that the care is right for you.

It is important to understand how your health care plan operates, but far too often the tricky benefit jargon of “deductible, coinsurance, copay, and out-of-pocket max” get in the way. These hard to understand health care vocabulary terms are explained below to help make understanding your health care plan much simpler!

Deductible – the amount of out-of-pocket expenses you pay for covered health care services before the insurance plan begins to pay.

HSA-Eligible Plan	All covered services require you to meet your deductible first and then services will be covered through coinsurance.
PPO Plan	Some covered services require you to meet the deductible first, while other covered services are paid with a copay.
Helpful Hint!	The health plan comparison chart shows deductible amounts for Tier 1, Tier 2 and Tier 3, but you should think of your deductible as one sum of the money you have paid for your services.
Example	With a $1500 Tier 1 deductible on the HSA-Eligible Plan with single coverage, you pay the first $1500 of covered services yourself. If you have met this, you would pay an additional $100 towards your services and then would have met the Tier 2 deductible of $2,500.

Coinsurance – the percentage of cost of a covered health care service you pay once you have met your deductible.

HSA-Eligible and PPO Plans	For services covered by “coinsurance after deductible” the amount you pay in co-insurance continues to count towards meeting your next Tier deductible.
Coinsurance %	Most Tier 1 services are covered at “90% coinsurance after deductible,” while Tier 2 services are “75% after deductible and Tier 3 are “60% after deductible.”
Example	If you are on either plan and have hit your Tier 1 deductible and visit a Tier 1 urgent care provider, the plan covers that service at “90% coinsurance after deductible.” This means you will pay 10% of the cost of the visit and your insurance will cover the remaining 90%. The 10% you pay will count towards your deductible.