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A copayment is a defined dollar amount a patient pays for medical expenses. With many health insurance plans, a patient pays 100 percent of costs out-of-pocket until they have met their deductible. After meeting the deductible, a patient pays a copayment (often shortened to “copay”).
No. Health insurance plans set different copay amounts for different types of services, such as an emergency room visit vs. an office visit. For prescription drugs, most plans define different copayments for different categories (formulary tiers) of drugs. For example, a plan might have a $10 copay for a generic drug, $25 for a preferred brand-name drug, $50 for a non-preferred brand-name drug, and $100 for a specialty drug.
Plans may also require a mixture of copayments and coinsurance. For example, you may have a copayment for prescription drugs, but coinsurance for a hospital stay. And, insurance plans sometime “stack” copayments and coinsurance. For example, you might pay a baseline copayment of $100 for a hospital stay plus 20 percent of charges for healthcare services you receive during your stay.
Yes, almost all health insurance plans require the patient to pay more for an out-of-network service. Check your certificate of insurance, certificate of coverage, or summary plan description (SPD) to understand what portion of a given medical expense you will be responsible for paying. Some plans might not cover a service provided by an out-of-network. Others may require the covered individual to pay the difference between charges from an in-network and an out-of-network provider.