Copay In Medical Billing

Posted : admin On 1/3/2022
what is copay?
  1. Can You Bill A Copay
  2. Copay Definition In Medical Billing

Copayments are fixed dollar amounts (for example, $15) you pay for covered health service to the provider, usually when you receive the service.
Definition of terms: Copayment (copay): A predetermined fee for physician office visits, prescriptions or hospital services that the member pays at the time of service.

A fixed or set amount paid for each health care or medical service; the remainder is paid by the health insurance plan. In common parlance, copay is the term used. Synonym (s): out-of-pocket costs, out-of-pocket expenses. Copay amount for first 3 visits in each calendar year. If related to a condition that's covered by a special authority.: $0 (no copay) If not related to a condition covered by a special authority.: $30 each visit. Copay amount for each additional visit in the same year. With the conclusion of the mandated deferral, VA plans to begin billing Veterans in January 2021 for those postponed copays. In January, Veterans should receive a patient statement that includes new copay charges for any care or prescriptions from April 6, 2020, through December 31, 2020, and any unpaid copays from before April 2020. Copay is the fixed amount that you have to pay for your treatment. It can be a fixed amount per the nature of the treatment of a fixed percentage. The amount A deductible is the fixed amount that you have to pay as a share of your medical bill upon which your policy comes into.

Medicare Definition
• A copayment amount for each service you get in an outpatient visit. For each service, this amount generally can’t be more than the Part A inpatient hospital deductible. If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible.
What is copay in medical billing

“Emergency Medical Care” means care provided by the MSHG and or the MSHG Member Hospitals, at any of the MSHG Member Hospital Facilities, for emergency medical conditions. “ Financial Assistance Application Period ” means the period ending on the 240th day after the first post-discharge billing statement is provided to a patient.

• All charges for items or services that Medicare doesn’t cover.

Example: Mr. Davis needs to have his cast removed. He goes to his local hospital outpatient department. The hospital charges $150 for this procedure. His copayment amount for this procedure, under the outpatient prospective payment system, is $20. Mr. Davis has paid $85 of his $155 Part B deductible. To have his cast removed, Mr. Davis must pay $90 ($70 remaining deductible amount + $20 copayment amount). The amount you pay may change each year. The amount you pay may also be different for different hospitals. Note: If you have a Medigap (Medicare Supplement Insurance) policy, other supplemental coverage, or employer or union coverage, it may pay the Part B deductible and copayment amounts
Medicaid Co-payments guidelines
Co-payment and co-insurance apply to clients covered by the Non-Traditional Medicaid Plan. Clients are required to make a co-payment for the types of services listed below. The provider is responsible to collect the co-pay at the time of service or bill the client. The co-payment shall be collected even if the client has other third party coverage. An exception to this policy is that co-payments are not taken out for Medicare Crossover claims.
Medicaid will automatically reduce the payments for each of these services by the indicated co-payment or coinsurance amounts at the time of reimbursement. The amount of the co-pay is described on the attached Benefit Chart for Non-Traditional Medicaid Plan.
• Hospital inpatient and non-emergency use of Emergency Department
• Outpatient hospital services, including free standing surgical center services
• Office visits for physician services, except preventive services and immunizations
• Vision care over $30 a year
• Pharmacy Services
• Physical Therapy
• Occupational Therapy
Co-pay Maximum Per Client
The out-of-pocket maximum is $15.00 per month for pharmacy co-pays. For inpatient procedures, the maximum is $220 per year. For physician and outpatient procedures, the combined maximum out-of-pocket is $100 per year
Which Providers can charge a Co-pay?

Can You Bill A Copay

• Chiropractors
• Podiatrists
• Optometrists
• Physical, Occupational & Speech Therapists
• Hospitals (outpatient services except ER)
• Physicians & mid-levels (NP or PA)
• FQHCs & RHCs

How do I know to collect a Co-pay?

• First check eligibility on the participant to see if they are Medicaid eligible and co-pay exempt or not
• Then determine whether or not the services you are about to render are subject to Co-pay by using this guide.

Who is exempt from Co-pay?

• A child with family income less than 133% FPG
• An adult with family income less than 100% FPG
• A pregnant or post-partum woman
• Children in foster care

Copay Definition In Medical Billing

• Those women who are eligible due to breast or cervical cancer
• Those on Hospice
• Those in Long Term care facilities
• Those on A&D or DD waiver
• Those who have primary insurance other than Medicaid
• Native Americans/Alaskan Natives
• Members who have reached a 5% CAP (a member who has paid out 5% or more of their monthly income is exempt for the remainder of the month)
• Workers with Disabilities Providers do not need to remember all these exemptions – the eligibility information provided by the system will reflect them.

What services can a provider charge a Co-pay for?

• Chiropractic services-services performed by a chiropractor.
• Podiatrist services-services performed by a podiatrist.
• Optometrist services- General Ophthalmological services billed by an Optometrist
• Physical, Occupational & Speech Therapy Services rendered in the therapist’s office or as an Outpatient hospital service

What services are subject to Co-pay?

• Outpatient Hospital –any of the services on this list performed in an outpatient hospital setting, except the emergency department
• Physician office visit-services provided at a doctor’s office unless preventive, family planning, or pregnancy-related.
• FQHC & RHC medical encounters, unless preventive, family planning, pregnancy-related or mental health.

Which Services are Co-pay exempt?

• Services performed in an Emergency room
• Services performed by an Urgent care clinic billing as an Urgent Care Facility
• Preventive services
• Family Planning
• Pregnancy related services
• Mental Health Services
• Services rendered that are $36.49 or less for the total claim.

What can I do if a participant doesn’t make their Co-pay?

• You can refuse to render services
• You can waive the Co-pay but you must have a written policy documenting under what circumstances you will waive it
• You can bill the patient
• Whether or not you choose to charge a Co-pay, when both the participant and the visit is subject to Co-pay provisions, the Co-pay amount will be deducted from your reimbursement.

What about the 5% cost-sharing cap?

• The copay will be tracked against the CAP. It is possible the exempt status may not be triggered due to the timing of providers submitting claims. DHW will handle reimbursements to participants should this happen.
• How long will reimbursement to the participant take?
– The length of reimbursement time will vary depending on the situation. I.e. provider billing, number of visits.

How do I know if I have met my 5%

CAP for Co-pay?

• You must calculate your CAP using the income information you provided Medicaid to determine your eligibility.
• EXAMPLE ONLY: If your family income is $1,635.00 a month you would need to go to 22 qualifying appointments in a month to reach your CAP. (Use this guide to determine “qualifying” appointments)
(Calculation for example: $1635 x 5% = $81.75 (Max out-of-pocket (CAP)) $81.75 divided by $3.65 = 22 visits)

Copayment for commercial insurance
Its differ patient to patient and plan to plan. For example see the different type of plan or treatment and the copayment.

VAPORHCS wants to keep you abreast of this upcoming change that was part of the nation's relief response to the COVID-19 pandemic so you can plan accordingly. There are many options and resources for Veterans in the brief article below.

Wednesday, October 28, 2020

(Updated November 6, 2020; see FAQs below)
Veterans should be aware and plan accordingly that the current suspension of VA collection actions and extension of terms of previous repayment agreements is scheduled to end December 31, 2020.

VA stopped sending monthly billing statements for medical care debt starting April 6, 2020. This change followed the President’s April 2 announcement that was part of the nation's relief response to the COVID-19 pandemic. In addition, all actions on debts owed to VA in the form of copayments under the jurisdiction of the U.S. Department of Treasury were suspended.

With the conclusion of the mandated deferral, VA plans to begin billing Veterans in January 2021 for those postponed copays.

In January, Veterans should receive a patient statement that includes new copay charges for any care or prescriptions from April 6, 2020, through December 31, 2020, and any unpaid copays from before April 2020.

Veterans are not required to make payments until after December, but they can make them now if they want.

How do I pay my VA copay bill?

Veterans can pay their bill in any of these 4 ways:


Pay directly from your bank account or by debit or credit card on the secure website.

By phone

Call the VA at 888-827-4817. Be sure to have your account number ready.

By mail

Send your payment stub, along with a check or money order made payable to 'VA,' to the address below. Be sure to include your account number on the check or money order.

Department of Veterans Affairs
PO Box 3978
Portland, OR 97208-3978

In person

Visit your nearest VA medical center and ask for the “agent cashier's office.” Bring your payment stub, along with a check or money order made payable to “VA.” Be sure to include your account number on the check or money order.

The agent cashier can look up your billing information; just bring a photo ID card.

Agent cashier's office, Bldg. 100, 3rd floor (open M-F, 8 a.m.-4 p.m.)

3710 Southwest US Veterans Hospital Road

Portland, OR 97239-2964

Click THIS LINK for other details and answers about…

  • how to dispute your copay charges;
  • and how to request financial hardship assistance.

Frequently Asked Questions

(As of Novmber 6, 2020)

Why are Veteranscurrentlynot receiving monthlypatientstatements from the Department of Veterans Affairs (VA)?

Due to thepotentialimpactCOVID-19may haveonVeterans’financial well-being,VAis notprinting and mailingpatient statements for health-care-associated costs from April 6, 2020, through December31, 2020. This means Veterans will not receive a monthly bill for any copaysincurredduring this time. VA will not be adding late charges or interest toaccountsor take any collection action onmedical caredebt until after December31, 2020.

When will theprinting andmailing of statements resume?

Patientstatements are expected to resumemail delivery in January 2021. Thosepatientstatements will includeunpaidchargesincurredprior to April 2020 and charges for services and medications received from April 2020 through December31, 2020.

How can Veterans find their current balances?

Veterans can obtain balances by calling 866-400-1238 or their local VA medical center’srevenue office.In November 2020, Veterans will receive a letter citing a current balance owed on accounts, with information on how payments may be voluntarily made.An outgoing call campaign will commenceonNovember6, 2020and will includeOffice of Community CareRevenue Operations staff callingVeterans with a greater than $2,000copayment balance.
What happens in January 2021 when statements resume? Will Veterans be required to pay the full statement balance?

In January 2021, Veterans will have the option to pay theircharges in full or arrange a payment plan to make smaller monthly payments. VA continues to consider Veterans who experienced changes to income and are struggling to make copayments due to COVID-19. Financial Hardshiparrangementscan also be requested at this timeor earlier.

How do Veterans make payments on their accounts if they are not receiving monthlypatientstatements?

Veterans can make payments to accounts during this time.Veterans or other payers must have theiraccount number.

  • An account balancecanbe obtained by:
  • Calling866-400-1238
  • Callingthelocal VA medical center’sfacilityrevenue office
  • ConsultingtheNovemberletter containing theiraccountbalance andadditionaldetails on the halt inpatientstatementprinting and mailing(Appendix A)
  • Methods by which a Veteran can pay on a balance
  • Callinga VA medical center facility revenue office
  • By mail:

Department of Veterans Affairs
PO Box 3978
Portland, OR 97208-3978

  • By phone at 888-827-4817

What debt relief options are available to Veterans?

Debt relief options are always available to Veterans. They include:

  • Set up a repayment plan
  • Request a waiver, write off or compromise of your debt
  • Request a VA Hardship Determination

To learn more, please visit