Insurance
Medical Insurance

How do health insurance copays work?

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Wiki User
2007-07-05 19:45:13

A co-pay is a flat payment that is the responsibility of the

patient that is assessed to an event; such as a doctor visit or a

prescription purchase. Similare to a copay...co-insurance is

typically a calendar year responsibility of the patient; such as

20% or 30% that is paid by the patient after meeting a deductible

(if applicable). There is usually a maximum out-of-pocket limit,

such as $1,000, $2,000 or higher that is the most a member can pay

prior to the plan paying 100% during a calendar or benefit year.

Copays do not always count toward the out-of-pocket limit. Example

of how a co-pay event might work.... Patient visits doctor for

cold. Patient pays $20 co-pay at time of visit.

Doctor bills insurance $100 for "sticker price" of the visit and

$20 for labwork.

Because the doctor is a contracted "in-network" provider, the

insurance carrier only allows $65 to be charged for the office

visit. Since $20 has already been paid by the patient, they send a

payment to the doctor of $45. The insurance carrier determines that

the $30 is subject to coinsurance and pays 80% and determines that

the patient is responsible for the other 20% - or $4. The patient

would ultimately receive a bill from the doctor for $4.


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