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Whats a co-payment?
Old 08-29-2015, 06:27 PM   #1
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Whats a co-payment?

I know this is a stupid question to most of you, but Ive never had insurance with a co-pay before. Im totally confused. The plan lists the following:

Deductible : $5750
Max out of pocket: $6600
Provider Choice: HMO
Co-Pays : Primary Doc = $20
Specialist = $50
Nothing listed about any co-insurance.

Its Jan 2nd and I need an allergy shot and go to a primary doc. Do I pay $20? Or do I pay the full amount and the co-pay is all I pay after I meet the deductible? There is nothing like an 80/20 co-insurance listed at all.
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Old 08-29-2015, 06:31 PM   #2
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In all likelihood, the $20 is what you pay the doc at the time of service.
It's not part of the deductible or out of pocket numbers.
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Old 08-29-2015, 06:41 PM   #3
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Yep, that is how I read it.

Really bugs me that co-pays are not considered part of max out of pocket as it would be pretty easy to rack up a lot in co-pays seeing a specialist for a serious problem.

Maybe they count towards it for some plans ?
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Old 08-29-2015, 07:02 PM   #4
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So the office visit is $20 but any tests or procedures is what goes towards the deductible?
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Old 08-29-2015, 07:10 PM   #5
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Co-pays are a fixed dollar amount, co-insurance is a percentage of the cost. Co-pays count towards out of pocket max but not towards deductible.


Typically you'll see co-pays for doctor visits and prescriptions and occasionally you'll have co-pays on some services.
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Old 08-29-2015, 07:30 PM   #6
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Originally Posted by Sunset View Post
Yep, that is how I read it.

Really bugs me that co-pays are not considered part of max out of pocket as it would be pretty easy to rack up a lot in co-pays seeing a specialist for a serious problem.

Maybe they count towards it for some plans ?
Under ACA all cost sharing counts toward OOPM, co-pay, co-ins and deductibles

https://www.healthcare.gov/glossary/...maximum-limit/
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Old 08-29-2015, 10:07 PM   #7
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Should be no co-pays for preventative health services.

https://www.healthcare.gov/preventive-care-benefits/
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Old 08-29-2015, 11:22 PM   #8
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The philosophy behind a co-pay is that you are less likely to run to the doc for every little splinter, sneeze or itch if you have to cough (sic) up 20 bucks each time. Without any co-pay that is exactly what folks would do too; see a doc to get an aspirin.

Pretty soon those folks with the 'Cadillac' plans, which includes plans with co-pays below $20 a visit, will be taxed. But, that's another topic....
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Old 08-30-2015, 06:54 AM   #9
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So the office visit is $20 but any tests or procedures is what goes towards the deductible?
It depends on the plan - in my current plan pretty much everything they do while I'm at the doc is covered by the copay, with the exception of x-rays.
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Old 08-30-2015, 10:16 AM   #10
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Originally Posted by skipro33 View Post
The philosophy behind a co-pay is that you are less likely to run to the doc for every little splinter, sneeze or itch if you have to cough (sic) up 20 bucks each time. Without any co-pay that is exactly what folks would do too; see a doc to get an aspirin.

Pretty soon those folks with the 'Cadillac' plans, which includes plans with co-pays below $20 a visit, will be taxed. But, that's another topic....
This is where you lose me. With my current plan, which has no co-pay, I cant go to the doctor for every sneeze because I have to pay the full cost of the doctor visit which may be $100 or so (until I meet my deductible which is $3000). So it will be cheaper to go to the doctor for every sneeze with a $20 co-pay
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Old 08-30-2015, 10:18 AM   #11
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It depends on the plan - in my current plan pretty much everything they do while I'm at the doc is covered by the copay, with the exception of x-rays.
Including an allergy shot? Getting a boil removed? Cutting out an ingrown nail? Things like that are included in the co-pay? What about physical therapy?
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Old 08-30-2015, 10:20 AM   #12
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Including an allergy shot? Getting a boil removed? Cutting out an ingrown nail? Things like that are included in the co-pay? What about physical therapy?
It depends on your specific policy, which spells out what coverage you have.
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Old 08-30-2015, 10:31 AM   #13
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I have Kaiser permanente with a high deductible. My copay is a down payment that counts towards the deductible. I am billed for the balance until I've met my deductible. After the deductible is met I just pay the copay for non-preventive visits. No copay for something deemed preventative such as an annual physical, mammogram, etc.

The billing is at a negotiated rate which is the biggest reason to have insurance.
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