If you’re new to having insurance, then you’ve probably already noticed that insurance vocabulary terms can be confusing. When you first hear words such as copay, coinsurance, deductible, premium, and out-of-pocket maximum, it can take a little time and research to grasp what they all mean.
Luckily, we’re here to help! In this article, we’ll help you understand everything you need to know about copays: what they are, common examples, and situations where might you not have to pay one.
We’ll try our best to explain the concept in the most basic of terms, but you’ll need do your part, too. See, understanding the concept of copay is one thing. But learning what you’ll pay yourself for a copay is another. The amount you’ll pay for your copay will depend on a number of factors, including what type of health plan you have, what kind of health care provider you’re visiting and whether that doctor is in your network or not.
The best way to learn what you’ll be paying is to log onto myBlueCross and familiarize yourself with your policy. As soon as you know that, you can apply your own personalized information to the hypothetical scenarios below! Then, you’ll be able to walk away with a better understanding of what a copay is.
What is a copay?
A copay is the amount of money you pay when you go to a doctor or health care facility or when you pick up a prescription. Copays can vary by insurance plan and according to the type of health care provider you see. But at its most basic, a copay is a set amount of money you can expect to pay when you receive an eligible health care service.
What are some examples of copays?
There are a number of scenarios where you’d be expected to pay a copay. Here are a few to help you better understand the concept:
In-network doctor visits
You’re feeling sick, so you make an appointment to see your primary care physician. The doctor examines you, performs a test, and you gives you a diagnosis. Without insurance, this visit might cost around $150. But because you have insurance, you pay a copay of $45.
Rather than driving to see a health care provider, you opt for a virtual visit and consult with a medical professional by video or phone. Without insurance, this may cost $200. But with your plan, your copay is $45.
You need to address some specific health challenges, so you make an appointment with a specialist (note that if you have an HMO, you already got a referral to do this through your primary care physician). The specialist runs a number of tests. Without insurance coverage, the visit may have cost $720. Because you have insurance, your copay for the visit is $75.
You’re injured or ill and need to see a doctor immediately, so you go to the emergency room for treatment. The health care providers at the hospital examine you, perform some tests, and give you medications to help you feel better. Without insurance, this visit may have cost $2,000. With your plan, the copay is $450.
You go to your local pharmacy to pick up a medication that your doctor prescribed. Without insurance coverage, the generic medication may have cost $40. But with your coverage, you pay a generic prescription copay of $10. If your doctor prescribed a name-brand medication that’s covered by your insurance plan, rather than a generic, the cost may have been higher—say it was $350. Your copay for the medication would also be higher, for example, $30.
How do I know what my copay is?
Copays vary depending on a person’s insurance policy. As mentioned, the easiest way to find out what your copay is by logging into myBlueCross for more details.
Your insurance ID card may also list the copays you’ll pay when you visit different types of healthcare providers, such as an office visit, a specialist visit and an emergency visit. Another way to find out details about your copay is by asking your healthcare provider what you’ll be charged for the visit.
Are there times when I won’t pay a copay?
There are some scenarios where you won’t need to pay a copay. Most health care plans cover certain preventive services. That means that if you go to the doctor for particular needs, such as vaccines, well-woman visits, different screenings and tests, there may be no charge—but check your plan to learn more.
In addition, if you reach your out-of-pocket maximum, you won’t have to pay a copay for the rest of the policy year. An out-of-pocket maximum is a set amount determined by your health insurance plan that limits the amount you’ll pay for your covered health services in a year. So if the payments you make for coinsurance, copays, and other fees add up to meet your out-of-pocket maximum, your health insurance plan will pay for all other eligible costs for the year.
To better understand the concept of out-of-pocket maximum, consider this scenario. Jasmine’s insurance policy has an out-of-pocket maximum set at $5,000. Jasmine needs surgery, which will cost $20,000. She has a $1,000 deductible and 20 percent coinsurance. Jasmine will pay the doctor and hospital $1,000 for her deductible and $4,000 for co-insurance. Because that adds up to $5,000, Jasmine has reached her out-of-pocket maximum. Her eligible health costs will be fully covered by her insurance plan for the rest of the year. The only cost she’ll need to continue paying is her monthly premium.
Without a doubt, there’s a learning curve to understanding health insurance terms and practices. But as you learn more, you can feel confident in making the most of your health insurance coverage.
Now that you understand what a copay is, we hope you feel empowered to reach out and make an appointment with your health care provider today. Knowing what you know now, there shouldn’t be any surprises about what you’ll pay!