What is a Copay?

Health insurance companies in Texas are alike in that they are all part of the Affordable Care Act. This means they are required to offer certain medical benefits, and their plans all contain the same elements of a health insurance policy. Among these are deductibles, out-of-pocket maximums, and coinsurance. With each metal level, these benefits vary. Another of these health insurance costs is a copay. This is the amount you will pay when you visit your doctor or before you receive treatment at a medical facility. How this cost is paid can vary. We intend to assist you in clarifying some of the questions you may have about your copay and how it is administered.

Before we begin, we would like to explain how the parts of insurance play into your health insurance policy. Then we will explain what your copay means to you.

What are the Parts of Health Insurance in Texas?

Insurance plans have several pieces that work together to provide you with coverage. We would like to define a few of them for you.

DeductibleA deductible is one of the first terms you will hear when you talk about insurance. It is the amount you will pay out-of-pocket before the coinsurance portion of your policy begins. It is one of the primary factors that determine your cost of insurance. For the most part, the lower your deductible is, the higher your premium will be. If you increase your deductible, you can see a lower monthly premium. A deductible is based on a calendar year and refreshes every year.

Coinsurance – Your coinsurance begins once you meet your plan’s deductible. It is the cost-sharing portion that factors into how much you and the insurance company will pay for your medical care. It is on a percentage scale from 50/50 to 80/20, depending on the metal tier plan and the insurance company you select. You can find details in your Summary of Benefits. You will continue to pay your coinsurance until you reach your out-of-pocket maximum.

Out-of-Pocket Max: After you have met your deductible, you are now paying toward the maximum amount for your medical expenses. Once you reach the out-of-pocket maximum, your policy will pay 100 percent of the medical expenses for that individual on your policy for the remainder of the calendar year. A policy also has a family out-of-pocket max. When this amount is reached the entire family will have 100 percent coverage for the remainder of the year regardless of if they have met their individual out-of-pocket max. This generally applies to larger families with multiple deductibles.

Primary Care Physician: A Primary Care Physician (PCP) is the main doctor you see for your medical care. Most medical plans require that you select and coordinate with your PCP before you see a specialist or have other medical tests done. In addition, if you have certain medical plans, you must remain within your network of providers, or you may not have coverage.

Now let’s explain how your copay applies to the above.

What is a Copay?

Copays are fees you will pay when you receive covered medical care. You pay copays when you visit a healthcare provider, have a test done, or fill a prescription. They can be a flat dollar amount or a percentage of the visit and vary by treatment, medical event, and plan. You will find copays when you visit:

  • Primary Care Physician.
  • Specialist
  • Diagnostic Testing
  • Urgent Care
  • Emergency Room
  • Outpatient Facility (Diagnostic, Imaging, X-ray)
  • Pharmacy

Depending on your plan, copays can range from as little as $10 for a doctor’s appointment and climb above $1000 for an emergency room visit. Copays vary by individual and health insurance plan, so read your policy carefully.

Also, some health insurance plans in Texas will allow you to use your benefits right away, while others require you first to meet your deductible.

What Copay benefits do I have before my deductible?

All insurance companies, in accordance with the Affordable Care Act, must provide preventive and wellness services. These benefits are included in your copay, and doctors cannot assess any additional fee for them. Preventative health services can differ between adults, women, and children.

Adults: These will include screenings for blood pressure, diabetes, hepatitis, various cancers, tuberculosis, and STDs. It will also include adult immunizations.

Women: In addition to the adult services, birth control, breastfeeding support, diabetes, and other at-risk pregnancy screenings are included. Support for maternal depression also provided.

Children: Immunizations to age 18, well-baby/child visits, TB tests, screenings for vision, development, and autism. Regular development assessments are also conducted.

Insurance companies do not charge for preventive health services when you remain in-network. Preventative coverage is not covered when you seek treatment out-of-network. However, Blue Cross Blue Shield of Texas will provide out-of-network preventive care but at a 50 percent coinsurance rate.

What is copay versus coinsurance?

When you visit a medical facility, this can be a doctor, urgent care, or hospital for an illness or injury, the moment you walk in, they will ask you for your insurance card. They will verify your information and then ask you to pay your copay. This is the amount for your doctor’s office visit.

When we begin to discuss coinsurance, this is the amount you will pay after you’ve paid your copay. It is for any medical service that the doctor or facility provides other than preventative services. Think of it like an add-on. When you order a pepperoni pizza, you get just that. Your pepperoni is your copay. All other services above the normal visit are your extra toppings.

The benefit is that you don’t have to pay full price for these health care services. You share the cost with the insurance company. This will depend on the plan you choose and the metal tier you are on. Your cost share will be from 50/50 percent to 80/20 percent of the medical expenses.

Copays and coinsurance are paid until you reach your out-of-pocket max.

Do I pay my copay after I reach my out-of-pocket max?

Out-of-pocket max is the ceiling for health insurance in Texas for policyholders. Once you have paid the amount stipulated in your policy for your medical expenses, you do not have to pay for anything other than your premium for the remainder of the calendar year; this includes copays.  

There are some exceptions to the out-of-pocket max rule. Your medical expenses need to be medically necessary, and you still need to adhere to your health insurance policy guidelines.

Cover Mile can help you find the policy that best suits your health insurance needs in Austin or Dallas. You can contact your agents, and we can find the insurance plan that provides you with the coinsurance that fits your current situation.

How Does a Copay Affect My Health Insurance?

Your health insurance company cannot charge you higher copays for providing essential health care. By being part of the Affordable Care Act, they are mandated to provide the 10 Essential Health benefits. They include:

•   Outpatient healthcare

•   Emergency services

•   Hospitalization

•   Pregnancy, maternity, and newborn care

•   Mental health and substance abuse disorder services

•   Prescription drugs

•   Rehab and habilitative services

•   Laboratory services

•   Preventative and wellness services

•   Pediatric, including oral and vision care

Whether it be your selecting a PCP or choosing a metal level, Cover Mile is available to assist you with understanding health insurance in Texas. We aim to guide you through the purchase process and how to select the best policy for you and your family. Contact us today.

Frequently Asked Questions

  1. Do copays differ for different health needs?

    Copays are set by the insurance company and will vary by the level of provider you are seeing. You will pay one coverage level for your Primary Care Physician, another for a Specialist, and still another for Urgent Care and Emergency services. Copays also differ depending on which metal tier you are on. The higher the metal tier, the lower your copay will be. Bronze has the highest copays, and Gold has the lowest.

  2. Are copays more expensive if you have a different health insurance network?

    Copays do not change if your insurance is through a different network. Both HMOs and EPOs, like Oscar Insurance, share the same coverage for deductibles, copays, and out-of-pocket expenses.

  3. Is there a zero-dollar copay?

    Some health plans have no copays. Don’t let this fool you into thinking it is free health care. These plans are usually High Deductible Health Plans. This means that patients pay all costs out-of-pocket up to the deductible. This is also often the same amount as the out-of-pocket max. After this amount is reached, though, medical care is 100% until the end of the policy year.

  4. What is a copay card?

    Being able to spend as little as possible on insurance costs is everyone’s desire. One way drug manufacturers aim to assist with prescription costs is to issue copay cards. These are cards, or rather coupons, issued to lower costs on brand-named drugs only. These cards can also be received from your doctor, but most are provided by the drug manufacturer.