Copay (Copayment)
Plain English
A copay is a set amount you pay for a covered health care service, like $20 for a doctor visit or $10 for a prescription. You usually pay it at the visit. On many plans copays start after you've met your deductible; before that, you may pay the full allowed price. Your plan's summary shows which applies.
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Definition
A copayment, or copay, is a fixed dollar amount a health plan member pays for a covered service, such as $20 for a doctor visit, with the plan paying the rest of the allowed amount. Depending on the plan, copays may apply before or after the deductible is met, and they can differ by type of service, such as office visits, specialists, lab tests and prescriptions.
Why It Matters
Copays are what most people see, but they're only one of four costs: the premium, the deductible, the copay or coinsurance, and the out-of-pocket maximum. A plan with low copays can still cost more over a year if its premium or deductible is higher, so compare all four.
Real-World Example
HealthCare.gov's example: the allowed amount for a doctor visit is $100 and the copay is $20. If you've already met your deductible, you pay $20, usually at the visit. If you haven't, you pay the full $100. Plans with lower monthly premiums usually have higher copays, and plans with higher premiums usually have lower ones.
Common Misconceptions
- A copay is the whole cost of a visit. It's your share; the plan pays the rest of the allowed amount.
- Copays and coinsurance are the same thing. A copay is a fixed dollar amount; coinsurance is a percentage.
- Copays don't count toward anything. On many plans they count toward the out-of-pocket maximum; check your plan.
Key Takeaways
- HealthCare.gov: a copay is "a fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible."
- Copays can vary by service within the same plan, such as drugs, lab tests and specialist visits.
- Lower-premium plans usually have higher copays.
- Compare premium, deductible, copays and the out-of-pocket maximum together.
Frequently Asked Questions
What is a copay?
A fixed amount you pay for a covered health service, like $20 for a doctor visit, with the plan paying the rest of the allowed amount.
Do copays count toward the deductible?
It depends on the plan. Some plans count copays toward the deductible and some don't; many count them toward the out-of-pocket maximum. Your plan's Summary of Benefits and Coverage says.
What's the difference between a copay and coinsurance?
A copay is a fixed dollar amount, like $20. Coinsurance is a percentage of the allowed amount, like 20%.
Do I pay a copay before meeting my deductible?
On some plans, yes, for certain services like office visits. On others, you pay the full allowed amount until you meet the deductible.
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The factual claims on this page were checked against these sources. Rules and figures change, so check the source itself if you need to confirm the current version.
- healthcare.govCopayment - Glossary · HealthCare.gov (U.S. Centers for Medicare & Medicaid Services)
Educational information, not advice: This page is for general education only, not legal, financial, or insurance advice. Actual coverage, discounts, and requirements depend on your policy’s wording, your insurer, and the laws of your state. Confirm specifics with your own insurer or a licensed agent before making a decision. Insurpedia does not sell insurance and does not recommend specific insurers.