Copayments, or copays, are features of health insurance plans. More specifically, insurance carriers define them as an exact amount that healthcare beneficiaries pay for each medical service that the policy covers. But, following the copay, the insurance company steps in and pays the remaining balance.

Within the same plan, copays vary depending on the medical services. For instance, they depend on whether the service is essential or routine versus others that are less routine.

Additionally, copays tend to be lower for standard doctor visits versus a specialist visit. 

Meanwhile, copayments vary depending on the health insurance provider and the policy an individual has. For instance, they’re most common for: 

• Primary care physician office visits
• Specialist office visits
• Prescriptions
• Physical therapy
• Occupational therapy
• Speech therapy
• Mental health visits
• ER services or ambulance 

It’s more common to see copays with in-network services. This means you must pick a provider from the insurance company’s network list. On the other hand, if you go out-of-network, the copayment may not apply and you may be required to pay the full amount of the bill, or a coinsurance percentage. 

Related Terms: Health Insurance, PPO