Copays - help me understand

[Plateau Mama]

I've never had a copay. My husband is taking a new job and we now will have a copay. What I don't understand is this, is the copay just $$ I pay to the dr in order to receive care or does I get applied to my bill?

 

Say my bill is $200 and my copay is $20. Will that $20 be applied to my bill or will I still owe $200 for my visit?

 

Another question. The insurance is the same company but it's a different plan. If I have some expenses on the old plan will I start over on my deductible when I switch or will it carry over to the new plan?

[ktgrok]

Think of the copay as the exam fee. There will be no other examination fee. Now, if they do tests, procedures, etc you may still get a bill for those. 

 

So I pay the copay for the kids to see the pediatrician, but then might also get a bill for a urinalysis or strep test or whatever, but no other exam fee. 

 

 

[SparklyUnicorn]

Basically the copay is $20 less that the insurance will have to fork over.  So if the total allowable is $200, the insurance would pay $180 because you are paying $20.  Allowable meaning that's the contracted rate between the doctor and the insurance company. 

 

In terms of the other question, that depends on a couple of factors so it's impossible for me to say.  Call them and ask.

 

 

[SparklyUnicorn]

Think of the copay as the exam fee. There will be no other examination fee. Now, if they do tests, procedures, etc you may still get a bill for those. 

 

So I pay the copay for the kids to see the pediatrician, but then might also get a bill for a urinalysis or strep test or whatever, but no other exam fee. 

 

Oh some insurance plans have a copay for everything.  So you go for an office visit...copay.  They send out for a separate lab....copay for the lab charge. 

[xixstar]

And it depends if you have a deductible or not.

 

If you have a deductible, the $20 will be applied to the $200 and you still owe the $180. This continues until you hit your deductible - if the deductible is $2000 it will take 10 appointments like your example to reach it.

 

After you reach the deductible, you the pay just the company for the dr visit. And as mentioned above, tests and such may be extra depending on your insurance.

Edited December 16, 2016 by xixstar

[KatieJ]

Co-pay are different for everybody As you can see in everyone's comments. It is not necessarily true that you will not have another charge after you pay the co-pay.

My co-pays are 20.00 and then the rest of the bill is sent thru insurance. Until I meet my deductible, I will still have to pay the rest of the bill whether it is an exam or tests. There are exceptions, as My healthy yearly checkups are covered, mamograms are covered. You need to speak,with your insurance company directly or your HR at the office.

[SparklyUnicorn]

And it depends if you have a deductible or not.

 

If you have a deductible, the $20 will be applied to the $200 and you still owe the $180. This continues until you hit your deductible - if the deductible is $2000 it will take 10 appointments like your example to reach it.

 

After you reach the deductible, you the pay just the company for the dr visit. And as mentioned above, tests and such may be extra depending on your insurance.

 

And then there is coinsurance sometimes.  So the same service could have a copay, coinsurance, and be subject to the deductible.

It IS as confusing as it sounds.

[historically accurate]

Think of the copay as the exam fee. There will be no other examination fee. Now, if they do tests, procedures, etc you may still get a bill for those. 

 

So I pay the copay for the kids to see the pediatrician, but then might also get a bill for a urinalysis or strep test or whatever, but no other exam fee. 

This is how our co-pays work. It's the total of the exam fee, but testing, etc will be billed separately.

 

However, our co-pay does not count toward our deductible, so if I go to a specialist, I pay $50 as a co-pay, but that amount doesn't get counted toward my deductible - so I will still owe $1500 in lab fees/testing fees/orthotics fees/etc. The deductible doesn't drop to $1450 - that irks me.

[Scarlett]

I hate co pays and percentages and trying to figure out if I have met my deductible. I prefer the 'clean' plans that pay nothing up to deductible and then pay 100%.

[xixstar]

This is not true for any insurance I've had. Services with a copay are outside of the deductible. You don't pay more than the copay, and the copay doesn't count towards the deductible.

 

Edit: that's the whole point of copays. If what I quoted above were true then you'd always pay the full charge until you met your deductible and nothing (or a lower percentage) after and the copay number would be irrelevant.

Maybe not yours but there is a large variation in plans and for someone reading a new insurance plan, there could be elements they don't even know to look for.

 

Our company offerred a plan with a deductible and copays. I was surprised to see the deductible this year -- but they have to balance the increase coat somehow. The deductible is low -- especially compared to the plan we selected -- and once they hit it, they just have copays.

 

There are soooo many options for plans these days.

[zyxwvut]

I get so confused about all this, too.

 

So, you pay a copay for whatever things they say you have to pay one for.

 

Then you have to pay the bill, until you hit your deductible, excepting for things like fully covered preventative care.

 

And then after your deductible, you still have to pay copays?

 

Is that right?

[xixstar]

I get so confused about all this, too.

 

So, you pay a copay for whatever things they say you have to pay one for.

 

Then you have to pay the bill, until you hit your deductible, excepting for things like fully covered preventative care.

 

And then after your deductible, you still have to pay copays?

 

Is that right?

For some plans, yes.

 

But it's all confusing and it can be a semantics game for some and depends on your plan.

[historically accurate]

I get so confused about all this, too.

 

So, you pay a copay for whatever things they say you have to pay one for.

 

Then you have to pay the bill, until you hit your deductible, excepting for things like fully covered preventative care.

 

And then after your deductible, you still have to pay copays?

 

Is that right?

 

You will always pay copays. I don't know of any that doesn't have copays once the deductible is hit; I don't know if you would still have copays after you hit that maximum amount for the year. 

 

My copay is my total for the service (I have regular doctor, specialist, urgent care, ER copays). As long as I only see the doctor in those scenarios I pay nothing besides the copay. If any of those do any testing, prescribing, etc, that would be paid 100% by me until I reach my deductible amount. After I reach the deductible, I pay 20% coinsurance on all of that "extra" stuff until I reach max out of pocket for the year. 

 

With my insurance, the copay amounts do not count toward the deductible or max out of pocket. 

 

Edited for clarity

Edited December 16, 2016 by beckyjo

[xixstar]

I'm skeptical. Plans vary, but terminology is regulated.

 

But the issue is more when someone goes to the doctor and they have to pay a "copay", often listed on the insurance card, because staff requires it and the card says there is one.

 

So I pay it but my plan actually states that I will only have a copay once I reach my deductible only. So, if I haven't met my deductible, I have to pay the difference.

 

So I didn't technically pay a "copay" - but if I didn't understand how all this works, when I look at the new plan benefits sheet and see it says that I have copay for medical appointments, I could incorrectly assume that is the only cost of I didn't know to also look at things like deductibles.

 

You're right, people can use terms incorrectly and often do.

[SparklyUnicorn]

The amount you pay after reaching your deductible is coinsurance. Are you sure your plan uses the word copay for it? Because those are two different things.

 

Not exactly.  Some services are covered at less than 100%.  The part not covered is the coinsurance.  It's kinda like a copay, but it's a percent rather than a flat amount.  Some services have copays AND coinsurance.  Some policies don't count coninsurance towards the deductible.  And there are other configurations as well.

[StephanieZ]

IME, copays are good, especially in the light of the high deductibles that are now the norm. When typical plans had low deductibles, then co-pays weren't as critical. Now, with so many plans having very high deductibles, co-pays can make a huge difference if you have an expensive medical need. 

 

I.e., I have a $2500 individual deductible, but a lot of frequent services (DR, specialist, labs, imaging, PT, etc) have specific co-pays. 

 

When I go see a DR when I'm sick, I just pay the $35 copay. That's it. Insurance picks up the rest. 

 

(When I go see the DR for preventive care, wellness, vaccines, mammogram, routine screening lab work, colonoscopy, and other PREVENTIVE items, I pay $0, as should anyone else on an ACA-compliant plan.)

 

When I go pay the specialist, I just pay the $50 copay. That's it. Insurance picks up the rest. 

 

If I have a bunch of labs done, I pay just the $50 lab copay. Or if I get imaging, I pay the $100 imaging copay (a big deal if you're looking at a $2000 MRI . . .)

 

So, when comparing plans, I prefer ones with lots of defined copays. 

 

Some plans have a % copay, like 30% instead of a straight $ amount. I don't like that in general, because 30% of a $3000 imaging study is a LOT more than $100. :) 

 

Hope this helps. 

 

 

[QueenCat]

I've never had a copay. My husband is taking a new job and we now will have a copay. What I don't understand is this, is the copay just $$ I pay to the dr in order to receive care or does I get applied to my bill?

 

Say my bill is $200 and my copay is $20. Will that $20 be applied to my bill or will I still owe $200 for my visit?

 

Another question. The insurance is the same company but it's a different plan. If I have some expenses on the old plan will I start over on my deductible when I switch or will it carry over to the new plan?

 

It's a new plan, with a new company so you will be starting over, as far as deductible. No carry over because it's a new plan, with a new employer/group.

[SparklyUnicorn]

It's a new plan, with a new company so you will be starting over, as far as deductible. No carry over because it's a new plan, with a new employer/group.

 

She said it is the same employer.  So it is possible it might carry over.

[SparklyUnicorn]

She said it is the same employer.  So it is possible it might carry over.

 

Well in fact if this is the same company and the switch is due to the employer switching, and they don't allow carry over of the deductible paid and it's within the time frame that it would count, I would consider that pretty lousy on their part. 

[Plateau Mama]

She said it is the same employer. So it is possible it might carry over.

Different employer. Same insurance company. I figured the deductible would reset but my mother insists that I just have to show proof of what I've already paid.

 

My son is scheduled for some LD testing at the end of January and it is very expensive so I don't want that to fall under the old insurance if deductible won't carry over.

[SparklyUnicorn]

Different employer. Same insurance company. I figured the deductible would reset but my mother insists that I just have to show proof of what I've already paid.

 

My son is scheduled for some LD testing at the end of January and it is very expensive so I don't want that to fall under the old insurance if deductible won't carry over.

 

Oh sorry...guess I read that wrong.

Then no that won't carry over.

 

However, there is something called "continuation of care".  I'd ask about that.  Sometimes when you switch mid treatment for something like that the old insurance is on the hook for some of it.  That I don't remember all the rules for though. 

[Um_2_4]

The more I read these threads, the more thankful I am for our awesome insurance that is no where near as confusing as all these plans you guys talk about.

I prefer copays, if they are true copays. I would call the 1800# for your plan to talk to a c/s rep and get clarification.

Some Dr offices don't even know how it works. Like our insurance had no copays for maternity care (office visits), but when I was pg with my 1st, the office kept trying to charge me a copay. I finally got it straightened out, but I guess the confusion was that the 1st visit had a copay till blood work confirmed the pregnancy :huh: .

We have known copays for sick visits/ER/Urgent care/meds. If ER visit results in admission, then no copay. No deductible. Max oop per year (which we have never meet thankfully) with no more copays if we were to ever hit it.

I dread DH switching to medicare once he hits that age (what is it now 62?) because I am sure it will be more confusing than our current plan.

[Plateau Mama]

Oh sorry...guess I read that wrong.

Then no that won't carry over.

 

However, there is something called "continuation of care". I'd ask about that. Sometimes when you switch mid treatment for something like that the old insurance is on the hook for some of it. That I don't remember all the rules for though.

Being that we won't have met our deductible yet my biggest concern is having to pay it twice. The testing will be a big chunk, if not all of our deductible. Also I need to have a procedure done. If I don't do it in Jan then I can do it until July which is doable but I'm in a lot of pain so it would be nice to do it sooner. I'm still praying for a cancelation so I can do mine before year end.

[QueenCat]

The more I read these threads, the more thankful I am for our awesome insurance that is no where near as confusing as all these plans you guys talk about.

I prefer copays, if they are true copays. I would call the 1800# for your plan to talk to a c/s rep and get clarification.

Some Dr offices don't even know how it works. Like our insurance had no copays for maternity care (office visits), but when I was pg with my 1st, the office kept trying to charge me a copay. I finally got it straightened out, but I guess the confusion was that the 1st visit had a copay till blood work confirmed the pregnancy :huh: .

We have known copays for sick visits/ER/Urgent care/meds. If ER visit results in admission, then no copay. No deductible. Max oop per year (which we have never meet thankfully) with no more copays if we were to ever hit it.

I dread DH switching to medicare once he hits that age (what is it now 62?) because I am sure it will be more confusing than our current plan.

 

Pretty sure medicare is 65 and just for the person who is 65 or older. You wouldn't be under his medicare. You get your own at 65.

[xixstar]

The amount you pay after reaching your deductible is coinsurance. Are you sure your plan uses the word copay for it? Because those are two different things.

I am very clear in the difference between copay versus coinsurance and pulled out the documents that also confirmed my understanding.

 

Yes the plan makes you meet a small deductible BEFORE you then pay copays.

 

The other plan makes you meet has a very large deductible before you start paying Coinsurance on majority of service types though there are a few small execrations that are a flat copay (getting primary care from the insurance company run clinics, for example).

 

Our company is not the only one that offered this type of plan. A friend consulted me when she was considering a new plan and they had a similar set up - she had never had a deductible before so it was confusing her because she associated a deductible with high deductible plans like mine and wanted to be sure she wasn't signing up for a plan like mine and could still count on having a copay versus coinsurance.

[jewellsmommy]

Being that we won't have met our deductible yet my biggest concern is having to pay it twice. The testing will be a big chunk, if not all of our deductible. Also I need to have a procedure done. If I don't do it in Jan then I can do it until July which is doable but I'm in a lot of pain so it would be nice to do it sooner. I'm still praying for a cancelation so I can do mine before year end.

 

I hope this isn't a dumb question, but are you sure you will have a deductible under the new plan? I only ask because you said co-pays and not co-insurance, but I know there are a million ways to structure these plans so that may not mean anything.

 

 

My insurance  has co-pays and a co-insurance but not a deductible.

I pay$25 at a my primary doc and $45 at specialists (co-pay).  I pay 20% of all lab and imaging services (co-insurance)

 

 

Ds's insurance has a deductible and a co-insurance (that is a % and is similar to a co-pay) but no actual set co-pay.

After we have paid $150 of incurred medical expenses, then we pay 25% of whatever the doc charges.

 

 

ETA: If you do have a deductible, unfortunately that will have to be met before they start the co-pay or co-insurance system (although preventative care should not be counted.) The company will not carryover from one plan to another. Dh switched jobs once where the insurance provider stayed the same, but each employer buys into separate plans, so all calculations re-started with the switch of plans.

Edited December 16, 2016 by jewellsmommy

[Plateau Mama]

I hope this isn't a dumb question, but are you sure you will have a deductible under the new plan? I only ask because you said co-pays and not co-insurance, but I know there are a million ways to structure these plans so that may not mean anything.

 

 

My insurance has co-pays and a co-insurance but not a deductible.

I pay$25 at a my primary doc and $45 at specialists (co-pay). I pay 20% of all lab and imaging services (co-insurance)

 

 

Ds's insurance has a deductible and a co-insurance (that is a % and is similar to a co-pay) but no actual set co-pay.

After we have paid $150 of incurred medical expenses, then we pay 25% of whatever the doc charges.

 

 

I have a copay of $xx, a deductible of $xxxx, and then OOP max of some other crazy amount. The only thing different from our current insurance is the copay. The deductible and OOP amounts are different but we've had them before so I understand how they work.

[Lawana]

Different plans are structured differently. Your plan may have you pay 100% of an office visit until you reach your deductible, or you may just pay a copay. The copay may or may not count towards your deductible and may or may not count towards your out-of-pocket max. The only way to tell for sure is to consult the plan documents or a representative. There is no absolute standard way deductibles, copay and coinsurance work.